>   ^Ar 


'^^^'•'of  trt^ 


^     THE     ^ 


Of      I* 


HEALTH 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/practicalmanualoOOsout 


//7T" 


A 


PRACTICAL   MANUAL 


GYNECOLOGY.  ^ 


BY 


G.  R.  SOUTHWICK,  M.D., 

ASSISTANT   PROFESSOR   OF   OBSTETRICS   IN  THE   BOSTON   UNIVERSITY    SCHOOL   OF 
medicine;     L.    M.    rotunda   hospitals,   DUBLIN. 


BOSTON  : 
OTIS    CLAPP    AND     SON, 


m8 


Copyright  iSSS, 
By   OTIS   CLAPP   &  SON. 


RAND   AVERY     COMPANV         14»i'.  .JWI.3  FRANKLIN   STREET,    BOSTON. 


PREFACE. 


Gynecology  is  a  child  of  the  present  generation. 
Its  growth  has  been  rapid  and  vigorous.  Yet  prog- 
ress in  this  specialty  has  been  in  the  direction  of 
surgery  rather  than  of  medicine ;  partly  because  we 
lack  a  thorough  knowledge  of  the  effects  of  drugs  on 
the  female  organism,  and  partly  because  a  surgical 
operation  appears  to  be  a  more  rapid  and  definite 
method  of   treatment. 

The  author  believes  that  uterine  diseases  are  largely 
due  to  faults  either  of  nutrition  or  of  vascular  or 
nervous  supply,  and,  like  other  diseases,  can  be  effect- 
ually and  permanently  cured  by  internal  medication. 
In  his  practice  and  experience  in  teaching  he  has  felt 
the  need  of  a  practical  manual  of  gynaecology  in 
which  the  general  practitioner  and  student  could 
readily  find  all  the  details  of  minor  surgical  gynae- 
cology, diagnosis,  local  treatment,  and  therapeutics  of 
uterine  diseases.  This  book  has  been  designed,  there- 
fore, as  a  safe  and  practical  guide  for  these  classes 
rather  than  for  the  specialist.  Hence  the  history, 
anatomy,  details  of  pathology,  and  major  operations, 
excepting  references  to  careful  descriptions  of  them, 
have  been  omitted ;  not  that  they  are  unimportant, 
but  because  they  are  easily  found  in  other  works,  and 


iv  ■  PREFACE. 

do  not  have   the   direct    and   practical   importance   of 
the  subjects  presented. 

The  indications  for  remedies,  the  recommendations 
for  methods  of  treatment,  and  operations  to  be  per- 
formed, are  based  upon  the  author's  observations  in 
many  European  and  American  hospitals,  upon  the 
study  of  all  carefully  recorded  cases,  so  far  as  he  can 
find  them,  in  a  thorough  search  through  medical 
works  and  journals  in  German,  French,  British,  and 
American  literature  covering  nearly  half  a  century ; 
upon  the  communications  from  his  professional  breth- 
ren ;  and  also  upon  his  own  experience  in  private, 
hospital,  and  dispensary  practice.  Many  clinical  cases 
are  quoted  to  illustrate  the  action  of  remedies. 

The  writer  has  endeavored  to  give  others  credit  for 
their  contributions  to  gynaecology,  either  in  the  list  of 
books,  of  journals,  of  authors,  or  among  the  foot- 
notes. He  also  desires  to  acknowledge  the  courtesy 
of  Drs.  Conrad  Wesselhoeft,  T.  F.  Allen,  James  B. 
Bell,  and  others,  in  allowing  him  the  use  of  their 
libraries,  from  which  much  valuable  aid,  otherwise 
unattainable,  was  obtained. 

Conscious  that  a  work  of  this  kind  must  be  neces- 
sarily incomplete,  suggestions  from  members  of  the 
profession,  statements  of  careful  verifications  of  symp- 
toms, and  reports  of  cases  cured  by  the  use  of  reme- 
dies employed  singly,  will  be  gratefully  received. 

G.  R.  SOUTHWICK. 

Boston,  136  Boylston  Street, 
Jan.  /,  1BB8. 


CONTENTS. 


CHAPTER  I. 

PAGE 

The  Causes  of  Gynecological  Diseases i 

Introduction.  —  Relation  of  Education,  Fashion,  Bodily  Posture,  and 
Society,  to  Uterine  Diseases.  —  Hygiene  for  Young  Women  and 
Girls. —  Influence  of  Marriage  and  its  Associations.  —  Influence  of 
Celibacy.  —  Question  of  Marriage  with  Existing  Uterine  Disease, 
as  Dysmenorrhoea,  Inflammatory  Disorders,  Amenorrhoea,  Fibroid 
Tumors;  or  Hereditary  Disease,  as  Cancer,  Tuberculosis,  or 
Insanity. 


CHAPTER   II. 

Minor  Surgical  Gynecology,  and  the  Principles  of  Local 
Treatment      .    

Hygiene  in  Gynsecology.  —  Question  of  Examination.  —  How  to  Ex- 
amine. —  The  Bi-manual  Examination.  —  The  Use  of  the  Sound  : 
Speculum  (Cylindrical,  Bivalve,  Sims'). —  Cleansing  the  Cervix. — 
The  Use  of  Tampons  :  Material,  and  how  to  make  them.  —  Appli- 
cations to  the  Cervix  and  Uterine  Canal :  Liquid,  Powder,  Oint-' 
ment,  Gelatine,  or  Cocoa-butter  Pencils. —  Indications  for  the  Use 
of  Alum,  Belladonna,  Boracic  Acid,  Bromide  of  Potash,  Calendula, 
Carbolic  Acid,  Chloral  Hydrate,  Eucalyptus  Globulus,  Glycerine, 
Hydrastis,  Iodine,  Iodized  Phenol,  Iodoform,  Iron,  Jequirity, 
Nitrate  of  Silver,  Opium,  Pinus  Canadensis,  Tannin,  Severe 
Caustics. — The  Hot-water  Vaginal  Douche. —  The  Spinal  Ice- 
bag. —  The  Spinal  Hot-water  Bag.  —  Pessaries,  how  to  select  and 
fit  them,  with  Rules  for  the  Same.—  Varieties  of  Tents,  and  how 
to  use  them,  with  Rules  for  the  Same.  —  Dilatation  of  the  Cervix 
by  Tents  ;  by  Goodell's  Method.  —  The  Use  of  the  Curette. 


vi  -  CONTENTS. 

CHAPTER   III. 

PAGE 

Diseases  of  the  Urethra 59 

Vascular  or  Neuromatoid  Growths.  —  Prolapse  of  the   Mucous   Mem- 
brane. —  Fissures   at  the  Neck  of  the   Bladder.  —  Urethritis.  — 
•   Therapeutics. 

CHAPTER   IV. 

Cystitis 67 

Etiology.  —  Symptoms.  —  Differential  Diagnosis.—  Prognosis.  —  Local 
Treatment.  —  Irrigation  of  the  Bladder.  —  Medicated  Fluids.  — 
Therapeutics. 

CHAPTER  V. 

Pruritus  Vulvae 75 

Parasites  of  the  Vulva.  —  Pruritus  Vulvaa.  —  Diet.  —  Local  Treit- 
ment.  —  Treatment  of  Pediculi,  etc.  —  Clinical  Cases.  ^  Thera- 
peutics. 

CHAPTER   VI. 

Laceration  of  the  Perineum 83 

Rule  for  deciding  on  an  Operation.  —  Support  given  by  the  Perineum 
and  Fascia  to  the  Uterus.  —  Injuries  to  the  Fascia. —  Time  to  per- 
form the  Primary  and  Secondary  Operation.  —  Forms  of  Lacera- 
tion of  the  Perineum,  and  their  Effect.  —  Perineorrhaphy  without  a 
Rectocele ;  with  a  Rectocele.  —  Emmet's  Operation.  —  The  Coil 
Suture. 

CHAPTER   VH. 

Abscess  of  the  Labia,  and  Phlegmonous  Inflammation  of 

the  Vulva 107 

Local  Treatment.  —  Therapeutics.  —  Digest  of  Remedies. 

CHAPTER  VIIL 

Vulvitis.  —  Vaginitis iii 

Forms,  Etiology,  Symptoms,  and  Diagnosis.  —  Prognosis.  —  Local 
Treatment.  —  Calendula,  Hydrastis,  Kreosote,  Corrosive  Subli- 
mate, Plantago,  and  Boracic  Acid  Cerate. —  Nitrate  of  Silver. — 
Forms  of  Vaginitis.  —  Etiology,  Symptoms,  and  Diagnosis.  — 
Complications.  —  Prognosis.  —  Local  Treatment.  —  Therapeutics 
of  Vulvitis  and  Vaginitis. 


CONTENTS.  vu 

CHAPTER   IX. 

PAGE 

Vaginismus.  —  Atresia.  —  Fistula 121 

Operations.  —  Therapeutics. 


CHAPTER  X. 
Puberty  and  the  Climacteric  Period 129 

Peculiarities  of  Each,  and  their  Hygiene.  —  Menstruation.  —  Albumi- 
nuria preceding  Puberty.  —  Remedies  for  it.  —  Chlorosis.  —  Thera- 
peutics. —  Chorea,  Hysteria,  Epilepsy.  —  Trance  and  Catalepsy.  — 
Management.  —  Therapeutics.  —  Nymphomania.  —  Remedies.  — 
Pollutions.  — Menstrual  Headaches. —  Therapeutics.  —  Menstrual 
Toothache.  —  Therapeutics.  —  Anomalies  of  the  Climacteric  Pe- 
riod. —  Clinical  Cases.  —  Therapeutics, 


CHAPTER  XI. 
Amenorrhoea 157 

Etiology.  —  Prognosis.  —  General  Treatment,  —  Therapeutics.  —  Clini- 
cal Cases.  —  Digest  of  Remedies. 


CHAPTER  XII. 

Menorrhagia  and  Metrorrhagia 169 

Etiology.  —  Local   Treatment.  —  Therapeutics,  —  Clinical    Cases.  — 
Digest  of  Remedies, 


CHAPTER  XIII. 

Vicarious  Menstruation .    .    ,    183 

Etiology.  —  Clinical  Cases.  —  Therapeutics. 


CHAPTER  XIV. 

Dysmenorrhcea,  or  Painful  Menstruation 186 

Neuralgic,  Ovarian,  Congestive,  Obstructive,  Membranous  —  Diff>;rcn- 
tial  Diagnosis. —  Treatment  of  each  Form.  —  Therapeutics. — 
Clinical  Cases.  —  Digest  of  Remedies. 


viii    ,  CONTENTS. 

CHAPTER  XV. 

PAGE 

Displacements  of  the  Sexual  Organs 205' 

Cystocele.  —  Rectocele.  —  Retroversion .  —  Retroflexion.  —  Antever- 
sion.  —  Anteflexion.  —  Lateroflexion.  —  Prolapsus  Uteri.  —  Inver- 
sion of  the  Uterus.  —  Treatment  with  and  without  Adhesion  and 
Fixation  of  the  Uterus.  —  Gymnastics  for  Uterine  Displacements. 
—  Local  Treatment. —  Mechanical  Treatment.  —  Therapeutics. — 
Clinical  Cases.  —  Digest  of  Remedies. 

CHAPTER  XVI. 
Endometritis.  —  Leucorrhcea 233 

Acute,  Chronic,  Cervical,  and  Corporeal  Forms. — Etiology  of  Leucor- 
rhcea.—  Local  Treatment.  —  Therapeutics.  —  Clinical  Cases. — 
Digest  of  Remedies. 

CHAPTER  XVII. 

Erosion,  Ulceration,  and  Laceration  of  the  Cervix  Uteri  .    251 

Effects  of  Laceration  of  the  Cervix.  —  Diagnosis.  —  Operation  for  its 
Repair,  i.e.,  Trachelorrhaphy. —  Effect  of  Operation  in  causing 
Sterility.  —  Details  of  Operation  and  After- Treatment. 


CHAPTER   XVin. 

Acute  Metritis 271 

Local  Treatment  and  Therapeutics.  —  Clinical  Cases. 

CHAPTER  XIX. 

Chronic  Metritis 273 

Synonymes.  —  Etiology.  —  Sub-involution.  —  Super-involution.  —  Care 
during  the  Puerperal  Period,  —  Local  Treatment.  —  Therapeutics. 
—  Clinical  Cases. 

CHAPTER   XX. 

Benign  Growths  of  the  Uterus 283 

Fibroid  Tumors  (Myoma,  Fibro-Myoma),  Fibro-Cystic   Tumors,  Fi- 
brous  Polypi,  Fungoid   Endometritis,  Glandular    Polypi,  Cellular  ■ 
Polypi   (Adenoma).  —  Relation   of    Fibroid   Tumors  to  Marriage 
and  Child-bearing.  —  Symptoms.  —  Diagnosis.  —  Differential  Diag- 
nosis. —  Local  Treatment.  —  Operations.  —  Therapeutics. 


CONTENTS.  IX 

CHAPTER  XXI. 

I'AGE 

Malignant  Disease  of  the  Sexual  Organs 310 

Sarcoma.  —  Corroding  Ulcer.  —  Epithelioma.  —  Etiology.  —  Symptoms. 

—  Diagnosis.  —  Diagnosis  of  Cancer  at  an  Early  Period.  —  Diag- 
nosis of  Benign  and  Malignant  Sclerosis  of  the  Cervix.  —  Cancer 
of  the  External  Genitals.  —  Differential  Diagnosis  of  Uterine  Fi- 
broids, Sarcoma,  Corroding  Ulcer,  and  Cancer.  —  Treatment, 
Radical.  —  Question  and  Choice  of  Operation.  —  Centra-indica- 
tions. —  Statistics.  —  Prognosis.  —  Palliative  Treatment.  —  Thera- 
peutics. —  Clinical  Cases.  ' 

CHAPTER   XXII. 

Pelvic  Cellulitis  (Parametritis),  Pelvic  Peritonitis  (Peri- 
metritis), and  Pelvic  Abscess 324 

Chronic  Atrophic  Parametritis.  —  Frequency  of  Peritonitis,  often 
called  Cellulitis.  —  Pelvic  Cellulitis.  —  Etiology. —  Clinical  His- 
tory. —  Diagnosis.  —  Prognosis.  —  Pelvic  Peritonitis.  —  Etiology.  — 
Clinical  History.  —  Diagnosis.  —  Differential  Diagnosis  of  Pelvic 
Peritonitis,  Pelvic  Cellulitis,  Pelvic  Abscess,  Fibroid  or  Ovarian 
Tumors,  and  Haimatocele.  —  Prognosis.  —  Pelvic  Abscess.  —  Eti- 
ology, Symptoms,  Diagnosis,  Prognosis,  and  Treatment.  —  Treat- 
ment of  Pelvic  Cellulitis  and  Peritonitis.  —  Electricity.  —  Thera- 
peutics of  Pelvic  Cellulitis,  Pelvic  Peritonitis,  and  Pelvic  Abscess. 

—  Clinical  Cases. 

CHAPTER   XXIII. 

Pelvic  H/Ematocele     . 349 

Etiology.  —  Symptoms.  —  Diagnosis.  —  General  Treatment,  —  Thera- 
peutics. 

CHAPTER  XXIV. 

Diseases  of  the  Fallopian  Tubes 354 

Diseases  not  admitting  of  Diagnosis  during  the  Life  of  the  Patient.  — 
Salpingitis,  Forms  of.  —  Diagnosis.  —  Treatment. 


CHAPTER  XXV. 

Ovarian  Neuralgia 357 

Etiology.  —  Symptoms.  —  Diagnosis.  —  Prognosis.  —  General    Treat- 
ment. —  Therapeutics.  —  Clinical  Cases. 


X  CONTENTS. 

CHAPTER  XXVr. 

PAGE 

Diseases  of  the  Ovaries 362 

Palpation  of  the  Ovaries.  —  Affections  of  tlie  Ovaries. —  Imperfect 
Development.  —  Ovaritis,  Acute  and  Chronic.  —  General  and  Local 
Treatment.  —  Clinical  Cases.  —  Therapeutics. 


CHAPTER  XXVII. 
Tumors  of  the  Ovaries  and  Broad  Ligaments 375 

Etiology  of  Ovarian  Tumors  in  Relation  to  Marriage.  —  Classification 
of  Tumors.  —  Malignant  Tumors.  —  Cancer.  —  Sarcoma.  —  Benign 
Tumors.  —  Dermoid  Cysts.  —  Ovarian  Tumors.  —  Parovarian 
Cysts.  —  Manner  of  Conducting  an  Examination.  —  Differential 
Diagnosis  of  Kinds  of  Cysts,  and  from  other  Conditions.  —  Differ- 
ential Diagnosis  of  Benign  and  Malignant  Tumors. —  Clinical 
History  of  Ovarian  Tumors.  —  Ovariotomy.  —  Reports  of  Cases  of 
Ovarian  Tumors  cured  by  Remedies. 

Index    .....•••••,•, 4°! 

Blank  Leaves  for  Memoranda 409 


ADDENDUM. 
Laceration  of  the  Cervix 399 


ILLUSTRATIONS. 


FIG, 


PAGE 

1.  Marks'  Chair j2 

2.  The  Harvard  Chair j2 

3.  Simpson's  Graduated  Uterine  Sound i  c 

4.  Simpson's  Graduated  Telescoping  Uterine  Sound 15 

5.  Delicate  Coin  Silver  Probe ic 

6.  Ferguson  Speculum jg 

7.  Nott's  Speculum j3 

8.  Graves'  Speculum jq 

9.  Cusco's  Speculum 20 

10.  Bozeman's  Uterine  Dressing  Forceps     .     .  ■ 21 

11.  Uterine  Syringe 22 

12.  Sims'  Speculum 24 

13.  Emmet's  Uterine  Applicator. zx 

14.  Gehrung's  Powder  Blower 26 

15.  Ointment  Injector 26 

16.  Reynolds'  Siphon  Bed-Pan ^c 

17.  Reservoir  for  Vaginal  Douche -ic 

18.  Davidson  Syringe ,5 

19.  Bow  Pessary 08 

20.  Harding's  Pessary     ...          og 

21.  Hodge's  Pessary -g 

22.  Smith's  Pessary _g 

23.  Thomas'  Modification  of  Smith's  Pessary 33 

24.  Hofmann's  Pessary ,q 

25.  Thomas'  Open  Cup  Pessary  for  Anteversion 43 

26.  Thomas'  Anteversion  Pessary  (Buckle)  .     .          4^ 

27.  Thomas'  Anteflexion  Pessary  (Closed  and  Open) 43 

28.  Thomas'  Anteflexion  Pessary  with  Stem 43 

29.  Graily  Hewitt's  Anteversion  Pessary 4-. 

30.  Cutter's  Ring  Pessary 44 

31.  Cutter's  Pessaries 4, 

32.  Donaldson's  Pessary     .  ' 44 

33.  Large  Rubber  Ring  Pessary ^r 


xil  '  ILLUSTRATIONS. 

FIG.  PAGE 

34.  Emmet's  Sponge  Tent  Carrier 51 

35.  Galvanic  Stem  Pessary 52 

36.  Goodell's  Modification  of  Ellinger's  Dilator 54 

37.  Wylie's  Modification  of  Sims'  Dilator 54 

38.  Thomas'  Blunt  Curette 57 

39.  T  for  washing  out  the  Bladder 69 

40.  Crutch  for  Perineorrhaphy 88 

41.  Pean's  Artery  Forceps S9 

42.  Emmet's  Scissors 89 

43.  Emmet's  Tenaculum 89 

44.  Sims'  Tenaculum 89 

45.  Sims'  Sponge-Holder 89 

46.  Russian  Needle-Holder 90 

47.  Emmet's  Twisting-Forceps 90 

48.  Sims'  Shield 90 

49.  Scissors  curved  on  the  Flat 91 

50.  Counter  Pressure  Hook 91 

51.  Solid  Tenaculum 90 

52.  Diagram  of  Freshened  Surface  with  Sutures  inserted  ....  92 

53.  Diagram  of  Section  in  Median  Line  after  the  Surfaces  are  tied,  92 

54.  Diagram  of  "  Butterfly  Freshening  "  with  Sutures  inserted    .     .  93 

55.  Diagram   of   Fteshened    Surface  for    Perineorrhaphy   with   a 

Rectocele 98 

56.  Diagram  of  Section  of  Perineum  through  the  Median  Line      .  99 

57.  Diagram  of  Perineum  when  drawn  together  by  Sutures  .     .     .  100 

58.  Diagram  of  Y-shaped  Laceration  of  the  Perineum loi 

59.  Diagram  of  Effect  of  Y-shaped  Laceration  of  the  Perineum,  as 

in  Fig.  58 102 

60.  Diagram  of  Perineal  Laceration  with  a  Rectocele 103 

61.  Diagram  of  Sutures  in  Perineorrhaphy  (Emmet's  Method)  .     .  105 

62.  The  Coil  Suture 106 

63.  Sims' Glass  Vaginal  Plug 122 

64.  Buttle's  Syringe 171 

65.  Nott's  Uterine  Elevator  and  Depresser 209 

66.  Gehrung's  Powder  Blower 240 

67.  Diagram  of  Uterus  with  Line  of  Cervical  Laceration  ....  252 

68.  Diagram  of  Effect  of  Laceration  of  the  Cervix 252 

69.  Diagram  of  Uterus  with  Line  of  Laceration  in  the  Cervix  .     .  2i;3 

70.  Diagram  of  Uterus  showing  Effect  of  Laceration  in  the  Cervix,  253 

71.  Sims'  Speculum 261 

72.  Emmet's  Tenaculum 261 

73.  Sims' Tenaculum 261 

74.  Heavy  Tenaculum 261 

75.  Dawson's  Scissors 261 


ILL  USTRA  TIONS.  xiii 


FIG. 


PAGE 

76.  Emmet's  Cervix  Scissors 262 

77.  Counter  Pressure  Hoolv 262 

78.  Emmet's  Wire  Twister 262 

79.  Sims'  Shield 261 

80.  Uterine  Sound 26'^ 

81.  Sponge-Holder 263 

82.  Diagram  of  Cervical  Laceration,  showing  Sutures  inserted  and 

Area  of  Freshening 264 

83.  Diagram  of  Cervix  after  Trachelorrhaphy,  with  the  Sutures  in 

place 265 

84.  Hofmann's  Pessary 042 

Photographic  Illustrations  of  Lacerations  and  Repair  of   the 

Cervix  Uteri 2co 


BOOKS    OR    PERIODICALS 

Consulted  or  Referred  to  in  the  Preparation  of  this  Manual. 


BOOKS. 

Abdominal  Surgery Greig  Smith. 

Acute  and  Chronic  Diseases Hartmami. 

American  System  of  Gynecology Mann. 

Amerilvanisclie  Artzneipriifungen C.  Hering. 

Annals  of  the  British  Homoeopathic  Society. 

Chronic  Diseases  of  the  Organs  of  Respiration     .  Meyhoffer. 

Clinical  Memoirs  on  the  Diseases  of  Women    .     .  Bermctz  and  Gattpil. 

Clinical  Therapeutics T.  Hoyne. 

Comprehensive  System  of  Materia  Med.  and  Therap.,  Heinpel. 
Contributions  to  the  Surgical  Treatment  of  Tumors 

of  the  Abdomen Keith. 

Cyclopaedia  of  Obstetrics  and  Gynsecology    .     .     .  Grandin. 

Diagnosis  of  Pathological  Anatomy Orth. 

Die  Neubildungen  des  Uterus Gusserow. 

Diseases  of  Females "Jahr. 

Diseases  of  Females  and  Children Williamson. 

Diseases  of  Females Peters. 

Diseases  of  the  Ovaries Olhausen. 

Diseases  of  the  Ovaries Tait. 

Diseases  of  the  Ovaries Spencer  Wells. 

Diseases  of  Women P.  Barnes. 

Diseases  of  Women Eaton. 

Diseases  of  Women     .     .  Graily  Hewitt ;  tA\t&di  hy  Dr. H.  Alarion  Sims 

Diseases  of  Women Leadam. 

Diseases  of  Women Liidlam. 

Diseases  of  Women May. 

Diseases  of  Women  and  Children Minton. 

Diseases  of  Women Thomas. 

Diseases  of  Women Winckel. 


BOOKS,   ETC.,   REFERRED   TO.  '     xv 

Diseases  of  Women  and  Children Guernsey. 

Domestic  Pliysician C.  Hering. 

Du  Traitement  Electiique  des  Tumeurs  de  I'Uterus,    Apostoli. 

Elements  de  Medicine  Pratique Jonsset. 

Gynakologische  Klinik w,  A.  Freund. 

Gynaecological  Operations Doran. 

Homoeopathy  the  Science  of  Therapeutics    .     .     .     Dunham. 

Klinische  Erfahrungen Riickert. 

Krankheiten  der  weiblichen  Geschlechtsorgane      .     Schroeder. 

Lectures  on  the  Materia  Medica c.  Dunham 

Lehrbuch  der  Homoopathie Von  Grauvogel. 

Lehrbuch  der  homoopatische  Therapie     ....  Sckwabe. 

Lessons  in  Gynaecology Goodell. ' 

Manual  of  Gynaecology Hart  and  Barbour. 

Manual  of  Pharmacodynamics      .......  R.  Huo-hes. 

Manual  of  Therapeutics ^.  Ht^^he's. 

Mass.  Bureau  of  Statistics  of  Labor.    Report  XVI. 

Materia  Medica .  r^     j.    ^t       ■, 

icun,d, Cowperthwaite. 

Materia  Medica Hering 

Materia  Medica  Pura \     S.Hahnemann. 

Mmor  Surgical  Gynecology />.  Munde. 

Neuralgia,  and  the  Diseases  that  produce  it  .     .     .     Anstie. 
New  Remedies jj^^^ 

On  Some  of  the  Diseases  of  Women Matheson 

Operative  Gynakologie Hegar u.' Kaltenbach. 

Ovarian  Tumors W.  Atlee. 

Pathologie  und  Therapie  d.  Frauenkrankheiten     .  A.  Martin. 

Pathology  and  Therapeutic  Hints Raue. 

Pathological  Anatomy Zieo-ler 

Practical  Medicine '.     '.    '.  Lolmi's. 

Practical  Medicine  .  ' ^^^ 

Practice  of  Medicine SmaU 

Principles  of  Biology '.'.'.     \  H.  Spencer. 

Prmciples  and  Practice  of  Gynaecology     ....  Emmet. 

Records  of  Homoeopathic  Literature Raue. 


XVI  BOOKS  OR  PERIODICALS 

Rest  for  Women-  during  Menstruation yacobi. 

Science  of  Therapeutics Baehr. 

Sex  in  Education Clarke. 

System  of  Medicine Arndt. 

System  of  Medicine Peppe)-. 

System  of  Medicine Reynolds. 

System  of  Surgery Helmidh. 

Textbook  of  Medicine  ahd  Surgery Rtiddock. 

Textbook  of  Medicine Stj-umpell. 

The  Building  of  a  Brain Clarke. 

Theory  and  Practice  of  Medicine Marcy. 

Transactions  American  Institute  of  Homoeopathy. 
Trans.  Internat.  Horn.  Congress.     London,  1881. 
Transactions  Mass.  Hom.  Med.  Society. 
Transactions  New-York  State  Hom.  Society. 
Trans.  9th  Internat.  Congress.     Washington,  1887. 
Transactions  Philadelphia  Obstetrical  Society.    1878. 
Trans.  World's  Homosopathic  Convention.     1876. 
Treatise  on  Ovarian  Tumors Peaslee. 

Uterine  Surgery J.  Marion  Sims. 

Uterine  Therapeutics Minton. 

Vesico- Vaginal  Fistulse Emmet. 

Virchow's  Archives. 

Ziemssen's  Cyclopaedia. 


PERIODICALS. 

Allgemeine  homoopatische  Zeitung. 

American  Homoeopathic  Journal  of  Gynaecology  and  Obstetrics. 

American  Homoeopathic  Review. 

American  Journal  of  Obstetrics  and  Gynaecology. 

American  Journal  of  Homoeopathic  Materia  Medica. 

American  Observer. 

American  Practitioner. 

Anriales  de  Gynecology. 

Annals  of  Gynaecology. 

Archiv  fiir  Gynakologie  und  Geburtshiilfe. 

Berlin.  Betr.  z.  Geburtshiilfe  und  Gynakologie. 


REFERRED    TO  IN  THIS  MANUAL.  xvu 

Boston  Gynjecological  Journal. 
British  Journal  of  Homoeopathy. 
British  Medical  Journal. 
Bull,  de  la  Soc.  Med.  Horn,  de  France. 
Bulletin  General  de  Therapeutique. 

Centralblatt  fiir  Gynakologie. 

Deutsche  med.  Zeitung. 
Dublin  Medical  Journal. 

Edinburgh  Medical  Journal. 

Hahnemannian  Monthly. 
Homoeopathic  Recorder. 
Homoeopathic  Journal  of  Obstetrics. 
Homoopatische  Vierteljahrschrift. 
Homoeopathic  World. 

Journal  of  the  American  Medical  Association. 
Journal  of  Homoeopathic  Clinics. 
Journal  of  Psychological  Medicine. 

London  Lancet. 
London  Medical  Record. 

Medical  and  Surgical  Reporter. 

Medical  News. 

Medical  Record. 

Monthly  Homoeopathic  Review. 

New- England  Medical  Gazette. 
New-Vork  Medical  Journal. 
North-American  Journal  of  Homoeopathy. 

Popular  Science  Monthly. 

The  Clinique. 

United-States  Investigator. 

United-States  Medical  and  Surgical  Journal. 

Volkmann's  Sammlung. 

Wiener  Klinik. 

Wien.  med.  Wochenschrift. 

Zeitschrift  fiir  horn.  Klinik. 
Zeitschrift  fiir  klinische  Medecine. 


LIST   OF   AUTHORS    MENTIONED    IN    THIS 
MANUAL. 


Allen. 

Andonit. 

Anstie. 

Apostoli. 

Arndt. 

Atlee. 

Baehr. 

Baertl. 

Bailey. 

Bantock. 

Barbour. 

Barnes. 

Battey. 

Bayea, 

Bennett. 

Bernutz. 

Bigelow. 

Black. 

Blake. 

Bonninghausen. 

Bozeman. 

Brodie. 

Brown,  Baker. 

Brown,  D.  Dyce. 

Brown-Sequard. 

Brownson. 

Burnett. 

Butler. 

Carfrae. 

Carlet. 

Chapman. 

Clarke,  Ed.  H. 

Cooper,  Robert. 

Cooper,  Isaac. 

Coxe. 


Craig. 

Crampton. 

Cutler. 

Da  Costa. 

Defriez. 

Dewees. 

Dewey,  John,  Ph.D. 

Donaldson. 

Doran. 

Doughty. 

Drysdale. 

Dudgeon. 

Duncan. 

Dunham. 

Dunn. 

Eaton. 

Eggert. 

Elb. 

Emmet. 

Engleman. 

Evetzky. 

Fellner. 

Flint. 

Fornias. 

Foulis. 

Fritsch. 

Frost. 

Freeman. 

Freund. 

Friedreich. 

Garrigues. 

Gehrung. 

Gilchrist. 

Goodell. 

Goubeyre. 


Goullon. 

Goullon,  H. 

Goupil. 

Gray,  J. 

Grauvogel,  von 

Guernsey. 

Gusserow. 

Hahnemann. 

Hale. 

Hall. 

Hammond. 

Hansen. 

Hart. 

Hartmann. 

Hausmann. 

Hawkes. 

Hegar. 

Hempel. 

Hennig. 

Hering,  C. 

Hering,  J.  R.  Coxe. 

Henriques. 

Hewitt. 

Hilberger. 

Hildebrandt. 

Hirsch. 

Hofmeyer. 

Holcombe. 

Homans. 

Hood. 

Houghton. 

Hoyne. 

Hoyt. 

Hughes. 

Hunter. 


LIST  OF  AUTHORS  MENTIONED. 


XIX 


Jackson. 

Jacobi. 

Jahr. 

Jermans. 

Johnson. 

Jousset. 

Kallenbach. 

Kaltenbach. 

Kafka. 

Kapper. 

Keith. 

Kent. 

King. 

Kippax. 

Kleinwaechter. 

Kiister. 

Kiistner. 

Landry. 

Leadam. 

Le  Fort. 

Levinstein. 

Lobeth. 

Loomis. 

Ludlam. 

Madden. 

Marcy. 

Martin. 

Martin,  A. 

Martineau. 

Matheson. 

McCHntock. 

Meadows. 

Meyhoffer. 

Mikulicz. 

Miller. 

Moffat. 

Moore. 

Moore,  J. 

Miiller,  CI. 

Munde. 

Neugebauer. 

Niemeyer. 


Noeggerath. 

Nothnagel. 

Nuiaez. 

Nunn. 

Olshausen. 

Orth. 

Fallen. 

Palmer. 

Planat. 

Polk. 

Pope. 

Porter. 

Post. 

Prall. 

Preston. 

Price. 

Prochownik. 

Ramos. 

Raue. 

Reed. 

Ring. 

Rockwell. 

Routh. 

Riickert. 

Ruddock. 

Russell. 

Salisbury. 

Sanger. 

Scanzoni. 

Schatz. 

Schauta. 

Scholtz. 

Schroeder. 

Schwabe. 

Schwartz. 

Sentin. 

Shuldham. 

Skene. 

Simon. 

Simpson. 

Sims,  H.  Marion. 

Sims,  J.  Marion. 


Small. 

Smith,  Harmar. 
Smith,  J.  H. 
Spencer,  Herbert. 
Stens. 
Sumner. 
Tait. 

Talbot,  L  T. 
Terry. 
Teste. 
Theobald. 
Thomas. 
Thompson. 
Thornton,  J.  K. 
Tilt. 

Tompkins. 
Tritschler. 
Utley. 
■  Velloso. 
Virchow. 
Wahle. 
Waldeyer. 
Wegner. 
Wells,  B.  H. 
Wells,  Spencer. 
Wesselhoeft,  C. 
Wesselhoeft,  W. 
West. 
Weston. 
Whiting. 
Wiedow. 
Wilcox. 
Williams. 
Winckel. 
Wiltshire. 
Winterburn. 
Winter. 
Woodbury. 
Worcester,  S. 
Wyder. 
Wylie. 


ARRANGEMENT. 


The  remedies  recommended  are  divided  into  four  classes. 
The  most  important  are  marked  with  a  double  bar  ( 1 1 )  ;  the 
next  important  have  a  single  bar  (|)  ;  the  ordinary  remedies 
without  a  bar ;  the  least  important,  and  those  remedies  seldom 
used,  are  placed  at  the  close  of  the  therapeutics  as  an  addi- 
tional list  for  consultation,  the  more  important  remedies  of 
which  are  printed  in  Itahcs. 

The  characteristic  symptoms  are  generally  printed  in  Italics, 
and  the  remedies  in  parenthesis  among  the  symptoms  refer  to 
those  remedies  having  similar  symptoms. 

The  digests  are  given  to  facilitate  more  accurate  prescribing, 
and  to  serve  as  suggesting  rather  t.  an  absolutely  indicating 
the  remedy.  Indeed,  the  same  hoius  true  of  those  remedies 
where  indications  are  given,  as  it  is  the  totality  of  the  symptoms 
of  the  case  which  is  our  real  guide.  The  indications  men- 
tioned, therefore,  are  those  more  peculiar  to  the  genital  organs, 
and  might  be  termed  the  beacon-lights  to  guide  us  to  the 
remedy.  The  study  of  Hughes's  Pharmacodynamics,  Cowper- 
thwaite's,  Hering's,  and  Farrington's  Materia  Medicas,  with 
these  symptoms,  will  be  of  material  help  in  deciding  on  the 
best  remedy. 

A  number  of  blank  pages  will  be  found  at  the  close  of  this 
volume  to  enable  the  reader  to  record  interesting  cases,  verified 
symptoms,  practical  observations,  etc  .  which  can  be  referred  to 
by  marginal  notes  in  the  text. 


PRACTICAL  MANUAL  OF  GYNECOLOGY. 


CHAPTER   I. 

THE    CAUSES    OF    GYNiECOLOGICAL    DISEASES. 

WHY  are  American  women  so  prone  to  diseases 
peculiar  to  their  sex  ?  It  may  be  considered  an 
open  question,  if  they  are  more  affected  than  women 
of  other  nations.  They  have  that  reputation  however  ; 
and  it  seems  to  be  true,  that  those  diseases  characterized 
by  various  disturbances  of  the  nervous  system  are  not 
only  more  frequently  met  with  in  the  United  States 
than  in  other  countricd;  but  are  also  increasing. 

A  young  woman  haio'  completed  her  education,  per- 
haps with  honor ;  as  a  girl  she  was  healthy  and  robust, 
but  for  some  occult  reason  a  peculiar  train  of  nervous 
phenomena,  :alled  hysteria,  is  developed. 

Like  the  fiy-wheel  of  an  engine  without  the  steadying 
influence  of  the  governor,  there  seems  to  be  a  lack  of 
correlation  of  the  nervous  forces.  The  nicely  adjusted 
balance  between  volition  and  'mpulse  is  lost,  and  the 
harmonious  action  of  the  vital  forces  destroyed.  The 
fault  may  be  detected  in  a  piece  of  machinery,  but  the 
human  organism  is  so  complex  in  it3  structure,  that 
neither  physiology  nor  pathology  will  always  enable 
us  to  determine  where  the  trouble  lies.  On  further 
inquiry  in  the  class  of  cases  referred  to,  we  are  liable 


2        CAUSES  OF  GYNECOLOGICAL  DISEASES. 

to  find  an  unnatural  condition  of  the  monthly  periods. 
They  may  be  irregular  or  profuse,  and  attended  with  a 
varying  amount  of  ovarian  pain.  The  patient  may  be 
subject  to  severe  headaches,  and  in  her  later  womanhood 
wonder  why  she  is  not  as  well  as  some  of  her  friends. 
Like  the  hot-house  plant  she  can  endure  but  little,  and 
is  easily  affected  by  her  surroundings.  Both  have  been 
forced  to  bloom  prematurely.  At  the  time  of  puberty, 
the  nervous  forces  are  directed  from  their  proper  chan- 
nels, and  physical  vigor  is  sacrificed  to  intellectual 
development.'  Instead  of  the  out -door  sports  and 
games  of  boys,  rowing,  skating,  etc.,  she  is  taught  that 
such  things  are  hoidenish.  While  the  boys  are  strength- 
ening their  muscles  with  plenty  of  out-door  air  and 
exercise,  she  is  practising  her  music,  or  reading  the 
latest  novel.  When  the  menses  appear,  she  is  seldom 
warned  and  advised  concerning  them.  Instead  of  tak- 
ing perfect  physical  and  mental  rest  at  these  times, 
she  goes  about  as  usual.  Imprudence  during  the  men- 
strual periods,  from  ignorance  of  the  consequences,  is 
a  fruitful  cause  of  disease.  No  mother  does  her  whole 
duty  to  her  daughter  who  fails  to  point  out  and  im- 
press upon  her  the  importance  of  this  one  thing.  At 
this  time,  too,  the  girl  just  entering  into  womanhood 
is  undergoing  the  cramming  processes  of  school  life 
and  various  accomplishments.  The  generative  organs, 
which  are  rapidly  developed  at  this  period,  suffer  from 
malnutrition  in  consequence  of  the  perversion  of  nerve 
force.  One  of  our  most  prominent  gynaecologists 
believes  this  is  a  fruitful  source  of  imperfect  develop- 
ment of  the  sexual  organs,  with  the  consequences  of 
various  "weaknesses"  and  sterility,  either  absolute  or 

'  Dr.  VViUiam  A.  Hammond  has  an  interesting  article  on  Brain-Forcing  in 
Childhood,  in  the  Popular  Science  Monthly  for  April,  18S7.  He  believes  that 
much  injury  is  done  by  sending  children  to  school  too  young,  and  with  too  great  a 
variety  of  studies. 


EDUCATION  AND  FASHION.  3 

relative.'  But  the  demands  of  education  are  not  the 
only  ones  made  upon  her.  Fashion  decrees  that  she 
must  wear  longer  and  heavier  skirts  and  dresses,  too 
often  suspended  from  the  waist  instead  of  the  shoulders. 
Tight-fitting  corsets  must  be  added  to  make  the  latter 
fit  well,  and  still  further  impede  the  free  circulation  of 
the  blood.  Habits  of  luxury  and  ease  also  play  a  role. 
Sitting  on  stuffed  easy-chairs  compresses  the  sides  of 
the  pelvis  and  the  blood-vessels,  instead  of  allowing  the 
pressure  to  come  upon  the  ischial  tuberosities,  where 
nature  intended.  Bodily  posture  is  not  without  its 
influence :  too  often,  in  sitting  down,  the  pelvis  is  tilted 
upward  and  the  body  forward,  the  erect  position  is  lost, 
and  the  weight  of  the  intestines  allowed  to  come  directly 
upon  the  contents  of  the  true  pelvis.^  A  similar  con- 
dition is  produced  by  wearing  high-heeled  shoes.  All 
these  tend  not  only  to  cause,  but  also  to  perpetuate,  a 
chronic  congestion  of  the  pelvic  organs  from  the  very 
beginning  of  her  sexual  life. 

One  of  the  best  ways  to  study  the  social  life  of  a  nation 
is  to  observe  the  caricatures  in  its  literature.  '  Among 

'  Dr.  Matthews  Duncan  attributes  to  it  not  only  sterility,  but  also  "destruc- 
tion of  sensuality  of  a  proper,  commendable  kind,  and  its  consequent  personal  and 
social  evils."  The  writer  is  quite  sceptical  concerning  this  statement,  as  patients  of 
practically  no  education  whatever  in  the  lower  classes  complain  of  this  fully  as  much 
as  the  better  classes.  He  would  also  ask,  why  should  higher  education  under  the 
same  conditions  affect'the  ovaries  of  a  woman  any  more  than  the  testicles  of  a  man  ? 

'  Emmet,  Principles  and  Practice  of  Gyneecology,  pp.  17-25. 

'  See  address  of  Dr.  Moore  on  the  Higher  Education  of  Women,  before  the 
British  Medical  Association,  British  Medical  Journal,  Aug.  14,  p.  295,  1SS6. 
Though  a  good  summary  of  the  opinions  of  various  persons,  he  does  not  found  his 
opinion  on  a  personal  investigation  of  statistics  bearing  on  this  question.  It  is 
commended,  however,  by  an  editorial  in  the  Journal  of  the  American  Medical 
Association,  Sept.  4,  p.  267,  1886.  A  very  interesting  reply,  by  Dr.  Lucy  M.  Hall 
of  Vassar  College,  to  Dr.  Moore's  address,  will  be  found  in  the  Popular  Science 
Monthly  for  March,  1887. 

'  See  also  Health  and  Sex  in  Higher  Education,  by  John  Dewej',  Ph.D. 
Popular  Science  Monthly,  p.  606,  March,  1S86. 

'  Compare  Herbert  Spencer's  Principles  of  Biology. 

^  Bodily  Posture  in  Gynaecology,  Dr.  S.  J.  Donaldson. 


4        CAUSES   OF  GYNECOLOGICAL   DISEASES. 

the  most  common  we  see  are  those  of  young  misses 
discussing  their  parties,  calls,  beaux,  fashions,  theatres, 
etc.  As  if  the  evils  of  education  and  fashion  were  not 
enough,  society  itself  must  conspire  against  them,  and 
demand  their  entrance  into  it  two  or  three  years  before 
that  of  the  opposite  sex,  the  boys,  who  meantime  have 
enjoyed  far  better  opportunities  for  physical  culture.' 
Girls  should  certainly  be  allowed  as  much  time  as  the 
boys  for  higher  education.  The  demands  of  society 
at  an  early  age  are  a  great  and  serious  mistake,  only 
adding  to  the  high  pressure  and  the  nervous  strain  to 
which  they  are  already  subjected.  Let  not  these  remarks 
be  misconstrued.  I  thoroughly  believe  in  the  higher 
education  of  women  in  whatever  direction  they  may 
manifest  peculiar  talent  and  ability,  and  I  also  believe 
in  giving  the  girls  a  fair  chance.^  It  is  not  so  much 
study  as  a  lack  of  physical  exercise,  late  hours,  improper 
food  and  dress,  which  generally  injure  a  girl's  health. 

The  remedy  for  these  things  is  simple ;  plenty  of  out- 
door air  and  physical  exercise,  rest  in  a  recumbent  posi- 
tion during  each  menstrual  period  until  regularity  in 
time  and  quantity  are  established.^  After  this,  she  need 
not  lie  down,  but  ought  to  have  both  physical  and  mental 
rest.  Teach  her  proper  care  of  herself,  and  the  danger 
of  suppressing  the  flow  by  wetting  the  feet,  or  sitting 
on  the  ground  or  on  cold  stones.  Keep  her  a  girl  and 
out  of  society  till  at  least  the  age  of  eighteen.     From 

'  Education  of  Girls  connected  with  Growth  and  Physical  Development.  By 
Dr.  Nathan  Allen.     In  Journal  of  Psychological  Medicine,  vol.  v.  Part  2,  London, 

1879. 

2  Dr.  Edward  H.  Clarke,  Sex  in  Education ;  or,  a  Fair  Chance  for  the  Girls. 
Dr.  Edward  H.  Clarke,  The  Building  of  a  Brain. 

3  Dr.  Mary  P.  Jacobi,  in  her  essay  on  The  Question  of  Rest  for  Women  during 
Menstruation  (p.  231),  expresses  her  opinion  that  "mental  work  exacted  in  excess 
of  the  capacity  of  the  individual  may  seriously  derange  the  nutrition  "  in  young 
persons,  but  she  thinks  there  is  no  need  of  rest  for  healthy  women  during  men- 
struation. 


INFLUENCE    OF  MARRIAGE.  5 

fourteen  to  seventeen  avoid  hard  study  and  the  reading 
of  light  hterature.  Moderate  study  with  out-door  air  and 
exercise,  going  to  bed  early  and  sleeping  long,  is  not  likely 
to  injure  any  one.  There  will  still  be  time  enough  for 
her  to  acquire  a  collegiate  education  if  she  wishes,  and, 
if  possible,  develop  into  a  strong  healthy  woman/ 

After  marriage  there  are  three  great  causes  of  uterine 
disease :  prevention  of  conception,  the  induction  of  abor- 
tion, and  lack  of  proper  care  during  and  after  parturi- 
tion. It  is  impossible  to  condemn  too  strongly  the  cold 
water,  acid,  or  astringent  injections  used  to  destroy  the 
vitality  of  the  semen,  or  the  various  mechanical  meas- 
ures to  prevent  the  entrance  of  the  spermatozoa  into  the 
uterine  canal.  The  injurious  effects  of  such  repeated 
injections,  when  the  generative  organs  are  excited  and 
congested,  must  be  apparent  to  every  practitioner. 
Very  many  seek  to  rob  Nature  of  her  due  by  withdrawal 
before  completing  the  sexual  act.  This  tends  to  pro- 
duce a  nervous  erethism  and  chronic  congestion.^  It 
thus  becomes  a  fertile  cause  of  disease,  which  is  prac- 
tised in  ignorance  of  the  consequences.  Nature's  laws 
may  be  infringed,  but  sooner  or  later  she  demands  a 
heavy  penalty. 

The  induction  of  abortion,  the  murder  of  a  child  by 
its  parent,  is  unquestionably  the  source  of  many  of  the 
diseases  which  come  to  the  gynaecologist  for  treatment. 
Its  pernicious  effects  are  so  plainly  evident  to  every 
physician,  it  needs  no  further  comment.     Lack  of  care 

"  The  health  statistics  of  female  college  graduates,  in  the  sixteenth  annual  re- 
port of  the  Massachusetts  Bureau  of  Statistics  of  Labor,  show  that  the  health  of 
such  graduates  bears  a  favorable  comparison  with  that  of  non-graduates.  It  is 
noticeable  that  only  about  one-third  of  the  number  had  married,  and  one-third  of 
these  had  not  given  birth  to  a  child.  The  report  unfortunatel)'  only  comprises 
54.65  per  cent  of  college  graduates,  as  the  remainder  did  not  answer  the  circulars 
addressed  to  them.  The  statistics,  therefore,  can  only  be  considered  approximately 
accurate. 

^  Goodell,  Lessons  on  Gynjecology. 


6     -    CAUSES   OF   GYNECOLOGICAL   DISEASES. 

during  and  after  parturition  is  more  often  the  fault  of 
the  doctor  than  of  his  patient.  Meddlesome  midwifery  is 
practised,  a  ruptured  perineum  is  not  sewed  up,  he  neg- 
lects to  inquire  after  the  various  functions,  and  see  for 
himself  that  they  are  properly  performed  after  delivery. 
The  patient  may  move  about  too  soon,  and  over-exert 
herself  in  various  ways.  She  may  be  subjected  to  coitus 
early,  which  never  should  take  place  during  the  three 
months  after  delivery.  Excessive  venery  and  too  fre- 
quent child-bearing  are  also  causes  of  much  subsequent 
trouble. 

It  may  not  be  out  of  place  to  mention  here  what  is, 
to  say  the  least,  a  great  mistake  and  a  positive  wrong  to 
our  patients.-  Many  a  physician  has  professed  to  under- 
stand and  treat  cases  of  uterine  disease,  of  which  in 
reality  he  knew  nothing.  Two  reasons  seem  to  account 
for  this :  first,  a  desire  to  make  money  out  of  the  case  ; 
second,  the  fear  lest  his  patient  should  not  think  him 
skilful  if  he  sent  her  to  some  one  better  informed  on  the 
subject.  In  consultations  some  doctors  seek  to  consult 
with  one  who  is  sure  to  agree  with  them,  no  matter  what 
the  treatment  has  been,  rather  than  one  who  might  advise 
differently  and  aid  them  in  the  treatment  of  the  case. 
This  may  seem  harsh  judgment  on  the  profession,  but 
such  instances  are  not  infrequently  observed.  The 
practice  of  medicine  should  be  for  the  good  of  the 
patients,  and  above  such  mercenary,  selfish  motives. 

Marriage,  and  especially  child-bearing,  apparently  con- 
fer a  certain  amount  of  protection  against  various  dis- 
orders of  the  climacteric,  particularly  the  growth  of 
fibrous  tumors  and  mucous  polypi.  On  the  other  hand, 
epithelioma  of  the  cervix  is  seldom  seen  in  the  sterile, 
and  with  few  exceptions  is  associated  with  laceration  of 
the  cervix  uteri.  The  marital  relations  serve  to  keep 
down  excessive  nerve  force  and  the  tendency  to  faulty 


INFLUENCE    OF  MARRIAGE.  7 

nutrition,  a^  shown  by  the  growth  of  various  neoplasms. 
So,  too,  in  the  unmarried,  those  who  are  constantly  and 
most  actively  employed  work  down,  so  to  speak,  this 
superfluous  energy,  and  suffer  less  from  morbid  growths 
at  the  time  when  functional  activity  of  the  sexual  organs 
ceases.  Nature  seems  to  have  ordained  that  the  cycles 
of  ovulation  and  menstruation  should  be  occasionally 
interrupted  and  held  in  abeyance,  and  that  the  progres- 
sive and  regressive  changes  in  the  uterus  during  its 
growth  and  involution  should  be  essential  to  the  health 
of  women.  Certain  it  is,  that  celibacy,  which  is  contrary 
to  the  design  of  nature,  tends  to  the  production  of 
certain  diseases. 

The  question  of  marriage  with  existing  uterine  disease 
not  infrequently  demands  bur  consideration.  There 
seems  to  be  a  feeling  among  the  laity  that  "  she  will  be 
all  right  when  she  gets  married."  In  the  great  majority 
of  cases,  this  is  quite  the  reverse,  and  the  patient's  com- 
plaints are  increased  instead  of  relieved.  There  are, 
however,  some  few  conditions  which  are  improved  or 
cured  by  pregnancy  and  child-bearing,  such  as  the  so- 
called  obstructive  dysmenorrhoea,  and  various  displace- 
ments of  the  uterus.  In  the  latter  class  of  cases,  it  is 
very  often  the  best  remedy.  Where  the  menses  are  a 
little  irregular  in  time  and  quantity,  the  marital  relations 
will  sometimes  regulate  them.  The  various  forms  of  hys- 
teria, and  all  inflammations  of  any  of  the  pelvic  organs, 
are  likely  to  be  increased.  Girls  who  have  reached  the 
age  of  twenty  without  any  sign  of  the  menstrual  flow 
should  be  examined  to  ascertain  the  cause.  It  may 
depend  on  defective  development,  and  conception  will 
not  be  possible.  If  the  marriage  takes  place  under  such 
a  condition,  both  parties  ought  to  know  there  will  be  no 
offspring.  Only  a  short  time  ago  I  was  consulted  in  a 
case  of  this  kind,  where  the  young  woman  had  married, 


8       CAUSES  OF  GYNECOLOGICAL  DISEASES. 

hoping  it  might  bring  on  the  menses,  and  conception 
result ;  but  all  to  no  purpose. 

Fibroid  tumors,  which  are  rare  in  young  women,  some- 
times raise  the  question  of  marriage.  Unless  the  growth 
be  very  small,  marriage  should  be  distinctly  forbidden 
till  after  the  tumor  is  removed.  The  increased  irrita- 
tion and  congestion  consequent  upon  the  new  relations 
would  tend  to  favor  its  growth.  Should  pregnancy 
ensue,  delivery  might  be  attended  with  serious  compli- 
cations from  dystocia,  or  post  partum  hemorrhage. 
Fibroid  tumors  have  but  little  vitality,  and  the  pressure 
to  which  they  are  subjected  in  labor  is  liable  to  cause 
their  death,  disorganization,  sloughing,  and  as  a  conse- 
quence puerperal  septicaemia.  I  have  in  mind,  while 
writing,  the  death  of  a  young  woman  from  this  cause. 

Young  women  in  whose  family  there  is  very  distinct 
and  decided  hereditary  disease,  such  as  cancer,  tuber- 
culosis, or  insanity,  for  two  or  three  generations  back, 
should  not  marry.  Not  only  will  they  bestow  a  fear- 
ful legacy  on  their  offspring,  but  pregnancy  and  child- 
bearing  very  decidedly  favor  the  development  of  these 
diseases,  particularly  the  two  first  mentioned. 


MINOR  SURGICAL   GYNAECOLOGY. 


CHAPTER   II. 

MINOR   SURGICAL     GYNiECOLOGY,    AND   THE    PRIN- 
CIPLES   OF    LOCAL   TREATMENT. 

NEATNESS,  both  in  person  and  methods  of  treat- 
ment, is  always  noticed  and  appreciated  by  ladies 
who  have  occasion  to  consult  a  physician  for  any  pecul- 
iar difficulty  requiring  an  examination.  Neat,  fresh 
linen  is  a  matter  of  no  little  importance.  The  finger- 
nails should  be  kept  short  and  clean,  to  avoid  giving  un- 
necessary pain  or  infecting  the  patient.  It  is  needless 
to  remark  that  the  utmost  delicacy  should  be  observed 
in  any  examination,  and  all  undue  exposure  carefully 
avoided.  This  is  of  so  much  practical  importance  to 
the  physician,  that  the  ordinary  manipulations  will  be 
described  in  some  detail. 

A  thorough  practical  knowledge  of  general  practice  is 
essential  to  any  specialist.  The  various  organs  of  the 
body  are  so  intimately  connected  that  one  influences 
another,  and  the  suffering  may  be  due  to  disturbance 
quite  remote  from  the  seat  of  the  disease.  In  no  branch 
of  medicine  is  this  more  true  than  in  gynaecology.  Not 
infrequently  the  trouble  is  due  to  imperfect  portal  cir- 
culation, or  the  disease  may  be  merely  the  expression 
of  general  debility.  On  the  other  hand,  there  are  some 
diseases,  more  especially  those  of  a  neuralgic  type, 
which  depend  on  some  form  of  uterine  trouble,  though 
the  local  symptoms  of  the  latter  may  be  quite  insig- 
nificant. 


lO  MINOR   SURGICAL   GYNECOLOGY. 

A  golden  rule  for  every  practitioner  to  follow  in  treat- 
ing* the  diseases  of  women  is  to  consider  carefully  every 
function  of  the  body,  and  in  every  case  the  totality  of 
the  symptoms.  Many  a  woman  has  suffered  more  from 
unnecessary  and  harsh  local  treatment  than  the  disease 
itself  would  have  caused,  if  a  little  common-sense  and 
hygiene  had  only  been  employed,  and  all  because  her 
physician  concentrated  his  entire  attention  on  that 
much-abused  organ,  the  uterus. 

Cleanliness,  rest,  and  good  nourishing  diet  to  build  up 
the  general  health  of  the  patient,  will  be  of  great  advan- 
tage. I  do  not  mean  to  say  that  local  treatment  is  un- 
necessary,—  not  by  any  means  ;  but  I  believe  it  is  very 
much  abused,  and  the  general  treatment  of  the  patient 
too  often  neglected.  Carefully  selected  remedies  should 
be  relied  on,  rather  than  local  applications,  for  the  per- 
manent cure  of  the  disease.  Why  is  it  necessary  to 
apply  remedies  locally  so  much  more  to  the  mucous 
membrane  of  the  genital  tract  than  to  the  mucous  mem- 
brane of  the  nose  or  throat,  in  treating  affections  very 
similar  to  each  other  .? 

A  careful  record  should  be  kept  of  every  case ;  the 
history  and  symptoms,  as  well  as  the  remedy  and  the 
results.  It  does  not  require  nearly  as  much  time  as  it 
would  seem  at  first  thought;  the  symptoms  once  noted 
do  not  have  to  be  repeated,  and  only  a  few  words  are 
necessary  to  record  the  results  at  each  subsequent  visit. 
The  more  important  cases  can  be  indexed,  and  in  a  few, 
years  valuable  experience  is  collected  in  a  ready  form 
for  reference. 

The  question  when  to  examine  a  patient  depends 
very  largely  upon  the  circumstances  of  the  case.  There 
is  a  great  difference  in  persons.  Some  will  not  consent 
to  it  though  it  may  be  very  necessary  ;  others  feel  they 
consult  the  physician  for  special  troubles,  and  that  he 


THE   EXAMINATION.  II 

fails  in  his  duty  if  he  neglects  an  examination  and  a  cer- 
tain amount  of  local  treatment,  though  the  latter  may  be 
nothing  more  than  a  dry  pledget  of  cotton.  The  doctor 
should  exercise  a  certain  amount  of  judgment  and  tact  in 
each  individual  case.  In  patients  suffering  from  consid- 
erable pelvic  pain,  severe  back-ache,  much  bearing-down, 
and  profuse  leucorrhoea,  or  much  loss  of  blood,  he  should 
urge  upon  them  its  necessity  ;  while  in  girls,  it  should 
be  the  last  resort,  and  carefully  avoided  as  far  as  pos- 
sible. Unless  patients  decidedly  object  to  an  examina- 
tion, it  is  well  to  make  a  thorough  one  at  the  beginning, 
enter  the  diagnosis  in  the  record,  and  also  re-examine 
opcasionally  even  if  there  be  no  local  treatment.  The 
record  of  the  case  is  thus  much  more  accurate  and 
valuable  for  future  reference. 

It  is  exceedingly  difficult  to  explore  thoroughly  the 
pelvis  with  the  patient  lying  on  a  low  lounge  or  couch. 
Ladies  naturally  dislike  to  climb  on  to  a  table  for  the 
purpose.  There  are  various  kinds  of  chairs  for  the  phy- 
sician's use,  good,  bad,  and  indifferent.  The  writer 
has  used  Marks'  chair  for  some  time  with  much  satis- 
faction. The  great  objection  to  it  is  the  expense,  and  it 
requires  some  strength  to  raise  a  heavy  person.  The 
Harvard  chair  admits  of  a  greater  variety  of  positions, 
but  has  a  more  repulsive  appearance  to  the  patient.  A 
small  cabinet  near  the  chair,  to  hold  the  instruments  and 
various  medicaments  for  local  use,  is  very  convenient. 
If  good  sunlight  cannot  be  had,  an  ordinary  candle  with 
a  good  reflector  attached  to  the  candlestick  affords  an 
excellent  and  cheap  substitute.  If  cheapness  is  a  sec- 
ondary consideration,  there  are  various  small  electric 
lights  which  are  very  serviceable.  With  the  patient 
in  the  dorsal  position,  which  is  the  only  one  allowing 
a  thorough  examination,  and  covered  with  a  sheet  to 
protect  her  person,  the  physician  is  ready  to  commence 


12 


MINOR  SURGICAL   GYNECOLOGY. 


the  examination.  Having  washed  his  hands  imme- 
diately before,  he  anoints  the  forefinger  of  the  left 
hand  if  he  wishes  to  examine  the  left  side  of  the  pelvis 
more  particularly,  or  the  forefinger  of  the  right  hand  if 


Fig. 


No.  4,  Marks'  Chair.     Showing  straight  stirrups,  made  without  the  back 
legs,  or  adjustment  for  elevating  front  of  seat. 


the  rz^-^^  side  of  the  pelvis.  Only  one  finger  need  be 
used,  for  as  much  can  be  felt  with  one  finger  as  with 
two,  by  pressing  firmly  backward  and  upward  on  the 
perineum.     Unless  there  is  some  reason  to  suspect  the 

presence    of   venereal    disease, 
pediculi,    or  some  affection  of 
the  vulva,  the    patient  should 
not  be  exposed  before  or  while 
introducing    the    finger.     The 
knuckle   can  be  passed   up  in 
the  cleft  of  the  buttocks,  over 
the  perineum,  and   the  tip  of 
the  finger   at   once  glides  into  the  vagina.     The  con- 
dition   of    the    perineal    body   should    be    noticed    by 
compressing  it   between    the  tip  of   the   finger  in  the 


The  Harvard  Chair. 


THE  BI-MANUAL  EXAMINATION.  1 3 

vagina  and  the  thumb  against  the  anterior  margin  of 
the  anus.  The  vaginal  walls,  whether  relaxed  or  not, 
dry,  moist,  or  hot,  next  deserve  attention.  The  cervix 
is  finally  reached.  Here  important  information  may  be 
obtained  from  its  shape,  feeling,  and  direction.  The 
condition  of  the  cervical  canal,  as  well  as  any  bulging 
into  the  vaginal  vault  anteriorly  or  posteriorly,  should  be 
carefully  noted.  The  lingers  of  the  other  hand  are  now 
placed  nearly  flat  on  the  abdomen  just  above  the  pubes 
and  corresponding  to  a  portion  of  the  pelvic  brim. 
Any  tenderness  or  localized  hardness  in  the  pelvis  is 
then  ascertained  by  seeking  to  bring  the  tip  of  the  in- 
ternal finger  and  the  external  fingers  together,  the  press- 
ure of  the  latter  being  exerted  downward  and  forward. 
This  is  called  a  bi-manual  examination,  and  is  absolutely 
essential  to  obtain  a  correct  knowledge  of  the  case. 

In  girls  and  unmarried  women,  enough  information 
as  to  pelvic  inflammation  or  uterine  displacement  can 
often  be  gained  by  a  rectal  examination  instead  of  the 
vaginal.  If  the  latter  be  necessary,  the  application  of 
cocaine  in  a  six-per-cent  solution,  or  cerate,  will  dimin- 
ish the  sensitiveness  of  the  hymen,  which  will  gradually 
stretch  with  scarcely  any  laceration  by  gentle  but  con- 
tinuous pressure  till  the  finger  enters  the  vagina.  I 
have  also  used  the  cocaine  successfully  when  the  vagina 
was  excessively  sensitive. 

Outlining  the  uterus,  which  is  indispensable  in  arriv- 
ing at  a  diagnosis,  is  so  often  very  difficult  for  the 
beginner,  that  a  description  will  be  given  in  some 
detail.  The  difficulty  is  frequently  increased  by  the 
almost  involuntary  contraction  of  the  abdominal  muscles. 
This  is  best  overcome  by  instructing  the  patient  to 
keep  herself  perfectly  relaxed,  to  breathe  out,  and  keep 
the  mouth  open.  If  this  is  not  sufficient,  endeavor  to 
engage  her  in  conversation  :  she  cannot  talk  and  keep 


14  MINOR  SURGICAL    GYNECOLOGY. 

the  abdominal  muscles  contracted  at  the  same  time. 
Then  crowd  the  internal  finger  well  up  into  the  anterior 
vaginal  fornix  at  the  junction  of  the  vagina  and  cervix, 
by  steadying  the  corresponding  elbow  against  the  hip, 
at  the  same  time  pushing  back  on  the  perineum  and  up 
in  the  pelvis,  while  the  outside  fingers  about  two  or 
three  inches  above  the  pubis  press  downward  and  a 
little  forward  into  the  pelvic  brim  in  the  median  line  ; 
next,  try  to  bring  the  fingers  of  both  hands  together, 
first  on  either  side  and  then  in  the  median  line,  where 
the  uterine  body  will  usually  be  felt.  If  this  manoeuvre 
fails,  place  the  tip  of  the  internal  finger  on  the  posterior 
lip  of  the  cervix,  and  raise  the  organ  well  up  and  a  little 
forward  in  the  pelvis,  at  the  same  time  pressing  down 
from  the  outside  as  before.  If  this  does  not  succeed, 
examine  both  sides  of  the  pelvis  for  any  lateral  displace- 
ment. If  the  uterus  be  retroverted,  the  upper  portion 
of  the  pelvis  will  be  empty,  the  fundus  bulge  against 
the  posterior  cul-de-sac,  and  the  cervix  point  upward  and 
forward.  Unless  there  is  a  flexure  of  the  cervix  upon 
the  uterine  body,  the  direction  of  the  former  will  indicate 
to  a  certain  extent  the  position  of  the  latter.  Besides 
the  position  of  the  uterus,  the  examiner  will  ascertain 
in  a  similar  manner,  whether  there  is  any  undue  tender- 
ness of  the  ovaries,  or  displacement,  the  existence  of  in- 
flammation, exudation,  or  the  presence  of  any  foreign 
growth. 

Having  obtained  all  the  information  possible  by  a 
digital  examination,  the  physician  is  ready  to  use  either 
sound  or  speculum.  The  former  is  a  safe  instrument  in 
careful  hands,  but  is  liable  to  provoke  some  irritation, 
and  should  never  be  used  without  a  distinct  indica- 
tion ;  moreover,  all  unnecessary  manipulation  should  be 
avoided. 

Most  physicians  have  the  ordinary  Simpson's  sound, 


THE    USE    OF   THE   SOUND. 


15 


with  the  little  knob  two  and  a  half  inches  from  the  tip, 
the  average  depth  of  the  normal  uterus.  In  addition 
to  this,  a  much  smaller  sound,  or  Sims'  probe,  will  be 
of  great  service,  where  it  is  necessary  to  ascertain  the 


P 

M 

WAV, 

m 

i 

11 


depth  and  direction  of  the  uterine  canal  with  the  least 
possible  irritation,  as  in  sub-mucous  fibroids.  The 
Simpson's  sound  should  be  passed  into  the  uterus  with- 
out a  speculum,  with  the  tip  of  the  forefinger  on  the 
OS  uteri  as  a  guide  ;  the  probe  must  be    used  with  a 


1 6  MINOR  SURGICAL   GYNAECOLOGY. 

speculum,  preferably  Sims'.  Either  is  absolutely  contra- 
indicated  by  any  inflammation  of  the  pelvic  organs, 
even  if  it  be  of  a  sub-acute  character,  endometritis  and 
sub-involution  excepted,  and  also  if  there  be  any  sus- 
picion of  pregnancy.  For  this  reason,  and  also  for  the 
important  information  it  gives  as  to  the  position  of  the 
uterus  and  probable  direction  of  the  uterine  cavity, 
digital  examination  should  invariably  precede  the  use  of 
either  sound  or  speculum. 

The  sound  is  most  often  employed  to  detect  the  pres- 
ence of  an  intra-uterine  growth,  such  as  a  fibroid  ;  to 
ascertain  the  relation  of  the  uterus  to  a  tumor  in  that 
portion  of  the  body ;  to  replace  the  organ  from  some 
malposition ;  and,  finally,  to  find  the  position  of  the 
fundus  uteri,  when  it  is  not  revealed  on  a  bi-manual 
examination.  The  necessity  for  using  it  in  the  latter 
case  is  very  rare. 

Having  previously  warmed  and  oiled  the  tip,  the  oper- 
ator guides  it  along  the  palmar  surface  of  the  finger  to 
the  cervical  canal ;  then,  by  depressing  the  handle  of 
the  sound,  the  point  readily  enters  the  uterine  cavity 
if  the  latter  is  directed  forwards.  Force  must  not  be 
used,  but  the  handle  held  lightly  between  the  thumb 
and  fingers.  If  the  fundus  lies  posteriorly,  the  tip, 
which  is  on  the  same  side  as  the  rough  surface  on 
the  handle,  should  be  directed  backwards.  When  the 
body  of  the  uterus  forms  an  acute  bend  or  angle  with 
the  cervical  canal,  some  little  difficulty  may  be  en- 
countered, but  is  easily  overcome  after  the  sound  is  in 
the  cervical  canal  by  raising  the  fundus  with  the  finger, 
so  as  to  straighten  out  the  angle  ;  and  in  some  rare 
cases  the  instrument  must  also  be  bent  to  correspond 
with  the  flexion,  or  even  given  two  curves,  one  for  the 
perineum,  the  other  for  the  direction  of  the  cervical 
canal. 


THE   USE   OF  THE  SOUND.  1 7 

A  decided  increased  depth  of  the  uterus  usually  points 
to  the  presence  of  some  growth  in  that  organ,  or  its 
adhesion  to  some  tumor,  which  is  drawing  it  up,  and 
stretching  out  the  cavity.  In  the  former  case  the 
uterus  is  low  down  in  the  pelvis  from  the  increased 
weight  ;  in  the  latter,  the  cervix  is  apt  to  be  high  up, 
and  hard  to  reach.  If  it  is  due  to  the  presence  of  a  sub- 
mucous fibroid,  the  examiner  will  meet  with  some  diffi- 
culty in  introducing  the  probe,  owing  to  the  obstruction 
in  the  cavity.  Where  a  fibroid  is  suspected,  it  can  al- 
most always  be  diagnosed  by  bi-manual  palpation.  Place 
the  patient  well  over  on  her  left  side  in  Sims*  position, 
and  with  the  aid  of  his  speculum  introduce  the  probe  — 
not  the  sound  —  very  gently  so  as  to  avoid  all  unneces- 
sary irritation.  Much  information  can  be  gained  in  this 
way  regarding  the  size,  attachment,  and  amount  of  bul- 
ging in  the  cavity.  If  this  is  not  sufficient,  the  cervix 
can  be  dilated,  the  uterus  forced  down  into  the  pelvic 
cavity,  and  its  interior  explored  with  the  finger. 

When  it  is  necessary  to  ascertain  the  relation  of  the 
uterus  to  some  growth,  place  the  patient  on  her  back, 
and  introduce  a  moderately  stiff  sound.  Note  the  direc- 
tion of  the  cavity  in  relation  to  the  tumor,  and  as  one  or 
both  hands  are  applied  to  the  latter,  motion  of  the 
fundus  uteri  communicated  by  the  sound  will  give  an 
approximate  idea  at  least  of  the  connection  of  the  uterus 
with  the  growth. 

No  attempt  should  ever  be  made  to  replace  the  uterus 
with  the  aid  of  the  sound,  if  there  are  any  signs  of  latent 
cellulitis.  This  is  a  rule  with  no  exception,  nor  should 
this  instrument  be  used  when  simpler  means  will  accom- 
plish the  same  end.  Peaslee's  sound,  which  is  large, 
thick,  and  less  liable  to  injure  the  uterus,  is  best  for 
this  purpose.  Place  the  patient  well  over  on  her  left 
side  in  Sims'  position,  with  the  hips  raised  about  three 


i8 


MINOR  SURGICAL   GYNAECOLOGY. 


inches  higher  than  the  level  of  her  shoulders.  Intro- 
duce the  sound,  and,  with  the  help  of  the  fingers  of  the 
opposite  hand  to  push  up  the  fundus,  gently  rotate  the 
instrument,  carrying  the  handle  round  in  a,  circle  about 
six  inches  in  diameter.  Never  turn  the  sound  on  its 
long  axis,  for  in  this  way  the  point  describes  a  circle, 
and  exerts  more  force  in  the  uterine  cavity.  But  if 
the  handle  of  the  sound  describes  a  circle,  the  point 
rotates  in  a  smaller  one  in  proportion  to  the  size  of 
the  former. 


Fig.  6.    Ferguson's  Speculum. 


In  many  cases  examination  with  the  speculum  fol- 
lows the  digital  examination.  There  are  three  principal 
varieties  in  common  use  :  the  cylindrical  or  Ferguson's, 
the   bivalve,  and  Sims'.     The  small  Nott  speculum  is 


Fig.  7.    Nott's  Speculum. 


best  for  young  unmarried  women,  and  is  also  very  good 
for  examining  the  rectum.  The  smallest  Ferguson 
speculum  is  preferred  by  some  on  account  of  the  reflect- 


THE   USE   OF   THE  SPECULUM. 


19 


ing  surface  increasing  the  amount  of  light  admitted 
into  the  interior.  The  bivalves,  of  which  disco's  and 
Graves'  are  very  good  examples,  are  most  used.  Sims' 
speculum  has  many  advantages,  but  requires  an  assist- 
ant to  hold  it.  The  various  contrivances  invented  to 
hold  the  instrument  are  expensive,  can    only  partially 


Fig.  8.    Graves'  Speculum.    Used  as  a  Bivalve  or  a  Sims'  Speculum. 


serve  the  purpose,  and,  in  fact,  are  seldom  used  by  the 
inventors  themselves.  Although  an  invaluable  and  in- 
dispensable instrument,  its  use  is  naturally  restricted 
to  a  great  extent  to  specialists,  and  the  performance  of 
certain  operations. 

In  using  any  speculum,  the  examiner  should  select 
one  corresponding  to  the  size  of  the  vagina.  This  is  of 
considerable  importance.     If  too  large,  it  is  very  pain 


20  MINOR  SURGICAL   GYNECOLOGY. 

fill.  If  too  small,  particularly  if  a  bivalve,  the  vaginal 
folds  drop  down,  making  it  very  difficult  to  obtain  a 
good  view  of  the  os  uteri,  besides  the  liability  of  severely 
pinching  them  between  the  blades  on  withdrawing  the 
instrument.  A  physician  who  needlessly  hurts  his 
patients  is  not  likely  to  be  very  popular  with  them. 

Before  introducing  the  Ferguson  speculum,  smear  it 
with  vaseline,  and  hold  the  cylinder  between  the  thumb, 
second,  and  third  fingers,  while  the  forefingers  of  both 


Fig.  9.    Cusco's  Improved  Speculum,  Folding  Handles. 

hands  separate  the  labia.  These  are  held  well  apart  by 
one  hand,  while  the  point  of  the  speculum  depresses 
the  perineum,  and  glides  downward  and  backward  into 
the  vagina.  This  instrument  is  very  apt  to  catch  on 
some  portion  of  the  nymphae  and  bulb  of  the  urethra, 
when  the  point  is  introduced,  and  hurt  the  patient. 
This  can  easily  be  avoided  if  the  operator  always  takes 
the  simple  precaution  to  look  through  the  speculum 
as  it  is  being  introduced.  Any  tendency  to  impinge 
against  the  nymphas  or  urethra  can  then  be  seen  at 
once  and  prevented,  A  speculum  should  always  be 
introduced  gently,  particularly  if  there  are  any  sensitive 


THE   BIVALVE   SPECULUM. 


21 


spots  in  the  pelvis,  and  the  point  directed  towards  the 
cervix,  the  position  of  v^^hich  has  just  been  ascertained 
by  the  finger.  The  use  of  the  cylindrical  speculum 
exposes  a  patient  much  more  than  the  bivalve,  though 
in  both  the  patient  occupies  the  dorsal  position.  More- 
over, the  bivalve  gives  a  much  more  satisfactory  view 
than  the  cylindrical.  In  the  great  majority  of  cases, 
then,  a  good  bivalve  speculum  will  be  the  best  for  the 
general  practitioner. 

This  instrument,  having  been  well  warmed,  and 
smeared  with  vaseline,  is  held  in  one  hand,  with  the 
forefinger  a  little  over  the  end  as  a  guide.      Passing 


Fig.  io.    Bozeman's  Uterine  Dressing  Forceps  (Self-holding). 


the  hand  beneath  the  sheet,  and  without  raising  the 
latter,  the  finger  guides  it  from  between  the  cleft  of 
the  nates  over  the  perineum  into  the  vagina.  Introduce 
the  long  diameter  of  the  oval  extremity  of  the  speculum 
through  the  vulvar  opening,  antero-posteriorly,  and  turn 
it  so  the  blades  correspond  to  the  vesical  and  rectal 
walls  after  one-third  has  entered  the  vagina ;  when 
fully  in,  partially  expand  the  blades  to  retain  the  instru- 
ment. Now  press  the  apron,  formed  by  the  sheet  over 
the  knees,  back  between  the  thighs,  without  raising  it, 
and  fold  it  around  the  speculum.  With  a  little  prac- 
tice, this  can  be  done  without  any  exposure  of  the 
external  genitals,  and  gives  the  patient  the  feeling  that 
her  person  is  protected.  The  os  can  then  readily  be 
brought  into  the  speculum  by  raising  or  lowering  the 
end,  or  expanding  the  blades  a  little  more.  The  latter, 
however,  need  not  be  expanded  so  far  as  to  cause  a 


22  MINOR  SURGICAL   GYNAECOLOGY. 

painful  stretching  of  the  vaginal  vault.  The  mucus 
can  be  wiped  away  with  absorbent  cotton,  held  by  a  pair 
of  dressing  forceps  having  a  bend  in  the  shank,  so  that 
the  hand  of  the  operator  does  not  obstruct  his  view. 
In  some  cases  of  endo-cervicitis,  the  mucus  in  the  cer- 
vical canal  is  so  tenacious  the  cotton  will  not  remove 
it.  However,  the  canal  can  usually  be  cleansed  by 
persistent  syringing  with  one  of  Goodyear's  uterine 
syringes,  by  attaching  a  short  piece  of  rubber  tubing 
to  the  nozzle  and  employing  suction,  or  by  twisting 
up  the  mucus  with  bits  of  dry  sponge.'  Before  making 
any  application,  a  towel  should  be  tucked  between  the 
buttocks  to  catch  any  fluid  which  may  escape  and  soil  the 
clothing.  This  is  particularly  important  where  iodine 
and  glycerine,  pinus  canadensis,  or  hydrastis  is  employed. 


Fig.  II.     Uterine  Syringe. 

Before  withdrawing  the  speculum,  the  blades  are  to  be 
partially  unscrewed,  but  not  enough  to  let  them  come 
together  and  pinch  the  vaginal  folds.  The  sheet  is 
then  pulled  forward  over  the  speculum,  and  the  latter 
removed  behind  it.  If  a  tampon  has  been  inserted,  it 
is  held  in  place  by  the  dressing  forceps,  while  the  spec- 
ulum is  withdrawn  over  it,  and  then  the  instruments 
are  removed.  A  digital  examination  is  now  made  with 
the  finger  to  be  sure  that  the  tampon  is  in  proper 
position. 

The  successful  use  of  Sims'  speculum  depends  largely 
on  the  proper  position  of  the  patient.  She  should  lie 
well  over  on  her  left  side,  the  left  arm  extended  a  little 
behind   her,  the   thighs    flexed   on    the   abdomen,   and 

'  The  peroxide  of  hydrogen  has  been  recommended  for  this  purpose  ;  but  the 
writer  has  not  had  much  success  with  it,  and  the  preparation  is  very  unstable. 


THE   USE   OF  SIMS'  SPECULUM.  23 

the  upper  limb  thrown  a  little  over  and  above  the  lower 
one.  Any  constricting  bands  about  the  waist  should  be 
loosened.  Besides  a  slight  cant  downwards  to  the  right 
side,  the  end  of  the  table  or  chair  towards  the  operator 
should  be  a  couple  of  inches  higher  than  the  end  occu- 
pied by  the  patient's  shoulders  and  head.  This  allows 
the  anterior  vaginal  wall  to  drop  forward  as  the  posterior 
is  retracted  by  the  speculum.  The  same  object  may  be 
obtained  in  a  simpler  way,  for  the  general  practitioner, 
by  raising  the  patient's  hips  on  a  hair  pillow  about  three 
inches  thick.  The  sheet  is  thrown  over  her,  so  that 
one  corner  is  folded  over  the  upper  limb  and  buttock, 
while  a  towel  is  tucked  in  between  the  thighs  and  under 
the  hips  to  protect  the  clothing.  The  operator  now 
takes  the  speculum,  which  has  been  previously  warmed 
and  oiled,  in  his  right  hand;  the  forefinger," as  a  guide, 
projecting  a  little  over  the  concavity  of  the  blade  which 
is  to  be  introduced,  while  the  left  hand  holds  the  opposite 
blade  to  steady  it.  It  is  then  passed  over  the  perineum 
into  the  vagina  edgewise  ;  after  the  blade  has  partially 
entered,  the  concavity  is  turned  towards  the  anterior  wall, 
and  care  taken  to  direct  the  point  of  the  instrument  well 
back  against  the  posterior  wall  of  the  vagina.  Gentle 
but  firm  steady  traction  is  then  made  backward  and 
a  little  upward,  the  nurse  or  assistant  meantime  lifting 
the  superior  labium  with  the  fingers  of  her  left  hand, 
while  the  right  hand  grasps  the  shank  or  central,  por- 
tion of  the  speculum,  the  blade  resting  over  the  junction 
of  the  thumb  and  index  finger.  Beginners  often  have 
some  trouble  in  using  Sims'  speculum,  which  would  be 
easily  obviated  by  keeping  the  inside  blade  well  against 
the  posterior  wall  while  introducing  it,  and  then  giving 
the  point  a  slight  forward  twist  to  tilt  the  cervix  out 
of  the  hollow  of  the  sacrum.  After  the  physician  has 
exposed  the  cervix,  the  nurse  holds  the  instrument  in 


24 


MINOR  SURGICAL   GYNECOLOGY. 


whatever  position  is  desired.  He  sits  behind  the 
patient  on  a  chair  or  stool  of  a  suitable  height.  At  his 
right  is  the  cabinet,  and  a  basin  of  warm  water,  in 
which  lie  the  depressor,  dressing  forceps,  tenaculum, 
and  sound  or  probe,  or,  if  an  operation  is  to  be  per- 
formed, whatever  instruments  he  may  desire.  In  the 
latter  case,  his  assistant  sits  on  the  right  to  hand  the 
instruments,  etc." 

Tampons  are  used  for  various  purposes,  but  chiefly 
for  the  application  of  medicinal  agents  to  the  cervix 
and  vagina.     It  is  not  necessary  to  make  them  of  ab- 


FiG.  12.    Sims'  Speculum.    Woman's  Hospital  Pattern. 


sorbent  cotton.  A  fine  quality  of  clean  white  cotton 
will  answer  every  purpose,  unless  the  absorbent  quality 
is  particularly  d.esired,  and  is  much  less  expensive.  The 
great  objection  to  cotton,  the  absorbent  especially,  is 
that  it  packs  down  and  feels  like  a  foreign  body  in  the 
vagina,  so  that  some  ladies  are  unable  to  wear  it.  In 
these  cases,  particularly  if  a  disinfectant  property  is 
desired,  marine  lint,  which  is  a  good  quality  of  tow, 
makes  an  excellent  substitute.  Where  elasticity,  and 
comfort  for  the  patient,  are  desired,  antiseptic  wool 
is  preferable.  This  is  also  best  suited  to  some  chronic 
inflammations    of    the    pelvic    tissues,    where    cotton 

'  The  best  Sims'  specula  that  I  have  seen  are  those  known  as  the  Woman's 
Hospital  pattern,  in  five  sizes,  manufactured  by  Hazard,  Hazard,  &  Co.,  New  York. 


FLUIDS,   POWDER,    OINTMENTS,    PENCILS.     25 


cannot  be  borne.  A  good  way  to  make  tampons  is  to 
unroll  a  sheet  of  unglazed  cotton  and  then  re-roll  it 
tightly  ;  when  the  roll  is  about  an  inch  thick,  separate 
it  from  the  rest  and  tie  to  it  strong  linen  thread  ten 
inches  long  at  intervals  of  an  inch  and  a  half,  then  cut 
the  roll  midway  between  the  threads.  This  will 
make  a  number  of  tampons  an  inch  thick  by 
one  and  a  half  long,  a  good  average  size  for 
general  use.  I  much  prefer  to  use  two  or  three 
small  tampons  to  one  large  one.  They  can  be 
introduced  more  easily,  with  less  loss  of  a  fluid 
application,  and  can  be  placed  in  the  pelvis  to  ^ 
better  advantage.  A  good  way  to  make  a  long  ^ 
flat  tampon,  corresponding  to  the  shape  of  the  ' 
vagina,  is  simply  to  cut  a  layer  of  the  wool  into  | 
pieces  an  inch  wide  and  two  and  a  half  long,  '^ 
tying  the  thread  to  one  end.  If  fluids  are  to  ^ 
be  applied,  such  as  glycerine,  or  combinations  2 
with  iodine,  calendula,  hydrastis,  etc.,  a  tam-  > 
pon  is  saturated  in  the  liquid,  and  the  excess  S 
squeezed  out  enough  to  avoid  dripping  before  % 
introducing  it,  particularly  if  containing  iodine,  ' 
hydrastis,  or  tannin,  which  would  badly  stain 
the  patient's  clothing ;  or  if  it  is  of  an  acid  or 
caustic  nature,  in  which  case  it  should  be 
squeezed  dry,  and  a  neutralizing  agent  applied 
on  tampons  immediately  after  to  avoid  irritating 
the  vagina  or  external  parts.  Liquids  can  be 
applied  nicely  to  the  cervical  canal  by  winding  a  bit  of 
cotton  over  Emmet's  applicator,  dipping  it  in  the  fluid, 
introducing  it  within  the  canal,  and  then  withdrawing 
the  stylet  so  as  to  leave  the  cotton  in  the  cervical  canal. 
This  can  be  withdrawn,  if  necessary,  by  the  dressing 
forceps,  or  a  thread  previously  tied  to  it,  but  often  comes 
away  of  itself.     If  it  is  to  be  the  carrier  of  powdered 


26 


MINOR  SURGICAL   GYNECOLOGY. 


substances  such  as  tannin,  alum  and  sugar  (equal  parts), 
iodoform,  etc.,  the  tampon  is  moistened  in  glycerine  or 
smeared  with  vaseline,  and  then  rolled  in  the  powder 
before  it  is  introduced  within  the  speculum. 
Powder  can  also  be  applied  to  good  advan- 
tage with  an  ordinary  insect-powder  gun. 

Ointments  are  smeared  on  a  tampon,  or 

injected  into  the  posterior  cul-de-sac  of  the 

vagina.       In    making  applications    to   the 

cervical  canal  and  cavity  of  the  uterus,  a 

whalebone  applicator  or  probe  is  wrapped 

w   with  cotton  dipped  in  the  liquid,  and  applied 

S   once  ortwice  to  the  canal.    The  mucus  must 

y^   be  removed  first,  as  previously  described. 

g        Pencils  of  iodoform,  tannin,  etc.,  are  also 

3  introduced  within  the  canal.     Astringents 

4  are  most  often  used  for  endo-metritis  ;  and 
9   caustics,  such  as  iodized  phenol,  nitric  acid, 

iodine,  etc.,  for  sub-involution  and  vegeta- 
tions with  consequent  metrorrhagia.  The 
use  of  an  applicator  wrapped  with  cotton 
requires  a  patulous  canal.  Where  the 
canal  is  small,  gelatine  or  cocoa-butter 
pencils,  inserted  with  the  aid  of  an  instru- 
ment made  for  the  purpose,  are  very  popular 
with  some  gynaecologists.  Those  most 
frequently  used  are  iodine,  gr.  v.-x.  ;  iodoform  and 
tannin,  gr.  v.,  gr.  iij.  ;  iodoform  and  alum  aa,  gr.  v.  ; 
hydrastis  canadensis,  gr.  v.  ;  and  I  might  add  bichro- 
mate of  potash,  I  X.  or  2  x.,  gr.  v. 
It  must  be  remembered,  however, 
that  the  great  majority  of  cases  for  ^'^  's-  ointment  injector. 
which  these  applications  to  the  uterine  cavity  are  made 
depend  almost  entirely  on  causes  quite  independent  of 
the  mucous  membrane  of  the  cavity,  such  as  sub-involu- 


DAVlDSOn    RU 


INDICATIONS  FOR  LOCAL  APPLICATIONS.     27 

tion,  displacement,  lacerations  of  the  cervix,  etc.  ;  and 
consequently  the  causes  need  to  be  removed  rather  than 
drugs  applied,  which  often  do  more  harm  than  good. 

The  question  of  making  local  applications,  in  the  great 
majority  of  cases  applying  for  treatment,  is  one  which 
must  be  settled  by  the  physician  himself.  While  a 
judicious  use  of  them  is  to  be  advised,  harm  is  often 
done  by  harsh  measures.  In  the  use  of  homoeopathic 
remedies  we  occupy  a  vantage-ground,  and  can  well 
afford  to  dispense  with  the  much  harsher  methods  which 
the  old  school  are  compelled  to  use.  Let  us-  use  our 
vantage-ground,  carefully  select  our  remedies,  and  with 
rest,  cleanliness,  and  simple  accessory  treatment,  we 
will  be  surprised  to  find  how  much  more  successful  we 
are  than  our  neighbors  who  stand  aloof.  Prescrib- 
ing one  carefully  selected  remedy  cannot  be  advocated 
too  strongly.  Not  only  will  the  results  be  better,  but 
more  accurate  for  future  reference.  A  list  of  the  more 
common  applications  is  given  below,  with  the  conditions 
for  which  they  are  employed,  for  the  convenience  of 
those  who  wish  to  use  them.  It  seemed  best  to  give 
the  indications  for  each,  as  the  local  treatment  used  by 
some  practitioners  seems  to  be  summed  up  in  glycerine 
and  iodine  for  every  case.  Many  physicians  recommend 
the  use  of  the  same  medicine  locally  which  is  given  in- 
ternally. This,  however,  hardly  belongs  to  those  reme- 
dies used  with  the  express  purpose  of  producing  local 
effects. 

ALUM.  Where  a  powerful  astringent  is  desired. 
It  is  good  for  profuse  leucorrhoea,  relaxation  of  the 
vagina,  and  slight  erosion  about  the  os.  In  these  cases 
it  should  be  diluted  one-half  with  pulverized  sugar, 
iodoform,  or  some  other  substance.  Powdered  alum 
will  often  check  oozing:  of  blood  from  the  surface. 


28  MINOR   SURGICAL   GYNECOLOGY. 

BELLADONNA  can  be  used  in  the  form  of  cerate, 
suppositories,  tincture,  or  fluid  extract.  Is  useful  as  a 
mild  narcotic  in  acute  inflammation  or  congestion  of 
the  pelvic  organs,  with  much  aching  or  throbbing  in 
the  vessels,  in  which  case  it  has  also  a  curative  effect ; 
also,  for  the  pelvic  neuralgiae  of  chronic  pelvic  cellulitis 
or  similar  conditions.  Watery  extracts  evaporated  to 
the  strength  of  the  alcoholic  are  preferable,  because  less 
irritating.  For  local  use,  I  have  the  solid  extract  of 
belladonna  rubbed  in  a  mortar  with  sufficient  water  and 
glycerine  to  dilute  it  to  the  strength  of  the  ordinary 
fluid  extract,  mixing  this  in  the  proportion  of  one-half 
or  one  drachm  to  an  ounce  of  glycerine  for  an  applica- 
tion. The  cerate  is  best  applied  by  smearing  it  on 
tampons  of  cotton  or  wool. 

BORACIC  ACID.  Its  action  is  the  same  as  borax, 
but  more  powerful.  May  be  used  in  cerate,  powder,  or 
solution  in  hot  water.  It  is  an  excellent,  non-irritating, 
odorless  disinfectant.  It  is  good  for  clear,  albuminous, 
or  lumpy,  but  not  for  yellow  leucorrhoea.  (A  solution 
of  one  drachm  of  the  bi-carbonate  of  soda,  —  saleratus, 
—  to  a  pint  of  water,  as  an  injection,  is  also  useful  for 
this  leucorrhoeal  discharge,  due  to  profuse  secretion  of 
the  glands  in  the  cervix.)  Sir  James  Simpson  recom- 
mended a  solution  of  five  to  ten  grains  to  an  ounce  of 
hot  water  in  the  "pruriginous  eruption  which  appears 
on  the  mucous  membrane  of  the  vulva,  and  extends  up 
along  the  vagina  as  far  as  the  cervix  uteri,"  also  in 
eczema  of  the  vulva. 

BROMIDE  OF  POTASH  in  a  saturated  solution  is 
sometimes  applied  on  a  tampon  for  its  soothing  effect. 

CALENDULA,  a  very  valuable  application  where  there 
are  any  solutions  of  continuity,  as  in  erosions  of  the  cer- 
vix ;  besides  its  use  as  a  cerate,  or  in  tincture,  it  is  an 


INDICATIONS  FOR  LOCAL   APPLICATIONS.      29 

excellent  remedy  to  mix  with  the  water  used  for  injec- 
tions in  any  abrasion  of  the  mucous  surface.  After  the 
patient  has  used  the  ordinary  cleansing  douche,  I  direct 
her  to  mix  two  teaspoonfuls  of  the  tincture  with  half  a 
pint  of  warm  water,  to  inject  it  while  lying  on  her  back, 
and  retain  it  from  twenty  minutes  to  half  an  hour.  The 
non-alcoholic  preparation  is  preferable. 

CARBOLIC  ACID  is  used  chiefly  as  a  disinfectant,  in 
the  form  of  a  2^0  or  5^  douche;  the  stronger  solution 
for  very  fetid  discharges,  the  former  for  ordinary  disin- 
fecting purposes.  It  has  also  been  used  as  a  mild 
caustic  and  stimulant  for  erosions  of  the  cervix. 

CHORAL  HYDRATE  is  a  good  anaesthetic,  and  also 
possesses  disinfectant  properties.  It  is  highly  recom- 
mended in  cancer  of  the  cervix,  applied  in  the  form 
of  a  solution,  one  drachm  to  the  ounce  of  glycerine,  or 
stronger  if  necessary.  It  is  one  of  the  best  deodorizers 
of  iodoform. 

EUCALYPTUS  GLOBULUS.  One  drachm  to  an  ounce 
of  glycerine.  This  is  a  useful  application  in  cases  of 
profuse  leucorrhoea,  and  superficial  erosions  about  the 
OS  with  congestion  of  the  cervix.  Belladonna  is  some- 
times combined  with  it,  if  there  is  also  much  active 
congestion,  throbbing  and  pain  in  the  pelvis. 

GLYCERINE  is  the  chief  agent  used  in  local  applica- 
tions. It  has  a  great  affinity  for  water,  and  consequently 
its  application  in  congested  conditions  of  the  pelvic 
organs  is  followed  by  a  profuse  watery  discharge,  mak- 
ing it  necessary  for  the  patient  to  wear  a  napkin.  It  is 
an  excellent  auxiliary,  as  well  as  vehicle  with  which  to 
mix  some  other  remedy  in  the  treatment  of  acute,  sub- 
acute, and  chronic  inflammatory  conditions.  The  physi- 
cian should  warn  his  patient  of  the  watery  discharge 


30  MINOR  SURGICAL   GYNAECOLOGY. 

following  its  application.  It  is  important  to  use  a  fine 
quality.     Price's  and  Bower's  are  the  best. 

HYDRASTIS  can  be  used  in  powder,  tincture,  or  cer- 
ate, in  cases  of  profuse  stringy  leucorrhoea,  endo-cervi- 
citis,  and  erosion  of  the  os.  It  is  often  combined  with 
glycerine,  one  part  of  the  tincture  to  four  of  the  glycer- 
ine. The  ordinary  fluid  preparations  produce  an  al- 
most indelible  stain,  and  the  patient  should  be  instructed 
to  wear  a  napkin.  Colorless  preparations  can  be  ob- 
tained, however,  and  are  quite  popular.  Among  these 
may  be  mentioned  Luytie's  hydrastis. 

IODINE.  Churchill's  tincture  is  the  best  for  applica- 
tions. It  is  employed  chiefly  as  an  alterative  and 
absorbent  in  cases  of  chronic  cellulitis  with  exudation, 
chronic  metritis  with  enlargement  of  the  uterus  and 
cervix,  sub-acute  and  chronic  ovaritis.  So  long  as  there 
is  acute  inflammation,  and  the  exudation  is  very  tender 
to  the  touch,  local  applications  on  tampons  are  counter- 
indicated.  In  applying  the  ordinary  tincture  of  iodine 
undiluted,  care  must  be  taken  not  to  let  it  touch  the 
vulva,  as  it  will  cause  sharp  burning  sensations  for  a 
few  minutes.  The  cervix  or  vaginal  vault  may  be 
painted  by  a  camel's-hair  pencil,  or  a '  bit  of  cotton 
wrapped  round  a  stick  dipped  in  the  iodine,  and  the 
surface  touched  with  it.  In  either  case,  be  careful  that 
all  excess  is  removed,  so  that  there  will  be  no  dripping, 
or  any  fluid  running  down  the  vagina  after  the  applica- 
tion. This  should  not  be  repeated  oftener  than  once  a 
week. 

A  more  common  method  of  application  is  to  mix  it 
with  glycerine,  one  part  iodine  to  eight  or  more  of  the 
former.  The  addition  of  ten  drops  of  tincture  of  aco- 
nite, or  fifteen  grains  of  chloral  hydrate,  is  useful  in  cases 
of  much  soreness  and  aching  in  the  pelvis.     Dr.  Emmet ' 

'  Principles  and  Practice  of  Gynaecology,  3d  ed.,  p.  572, 


INDICATIONS  FOR  LOCAL  APPLICATIONS.      31 

recommends  in  hemorrhage  from  fibroid  tumors,  the 
local  application  of  the  tincture  to  the  uterine  cavity  by 
means  of  a  little  cotton  wrapped  round  a  probe,  and 
saturated  in  the  iodine.  Methyl  iodide  has  been  re- 
cently recommended  instead  of  iodine,  as  it  is  said  to 
combine  the  absorbent  qualities  of  the  latter  with  some 
anaesthetic  properties. 

IODIZED  PHENOL.  Dr.  Robert  Battey '  suggested 
this  combination,  made  by  gently  heating  two  parts  of 
crystallized  carbolic  acid  with  one  of  iodine.  It  is  a 
mild  escharotic,  alterative,  and  a  favorite  application  of 
some  physicians  to  the  endometrium  for  sub-involution, 
chronic  metritis,  and  to  the  cervix  for  erosions,  endo- 
cervicitis,  etc.  This  is  sometimes  diluted  by  adding  an 
equal  bulk  of  glycerine:  I  consider  this  dilution  neces- 
sary for  its  use  within  the  uterine  cavity. 

IODOFORM  has  excellent  antiseptic  and  some  anaes- 
thetic properties.  The  odor,  which  is  an  objection  to  it, 
may  be  counteracted  by  chloral  hydrate,  oil  of  pepper- 
mint, or  balsam  of  Peru,  one  drop  to  the  drachm,  or  a 
couple  of  Tonka  beans  may  be  kept  in  the  powder.  It 
is  useful  as  a  dressing  after  operations,  for  erosions  of 
the  cervix,  and  to  destroy  the  virus  of  chancroids.  The 
application  of  iodine  is  sometimes  alternated  with  a 
tampon  saturated  in  the  following  mixture  :  iodoform, 
one  drachm  ;  chloral  hydrate,  twenty  grains  ;  glycerine, 
one  ounce.  Recently  iodol  has  been  introduced  as  a 
substitute  for  iodoform. 

IRON.  The  perchloride  or  persulphate  is  sometimes 
used  as  a  styptic  where  iodine,  tannin,  or  alum  fails. 

JEQUIRITY.  A  powerful  vegetable  caustic.  Dr. 
Porter  has  found  this  more  satisfactory  in  the  treatment 
of  granulations  of  the  uterus  than  any  of  the  liquid  or 

'  Amer.  Pract.,  February,  1877. 


32  MINOR  SURGICAL   GYNECOLOGY. 

solid  caustics.  He  macerates  five  fresh  beans  in  two 
ounces  of  cold  water  for  two  days,  then  adds  an  equal 
amount  of  hot  water,  filtering  it  as  soon  as  cool ;  one  part 
of  this  is  mixed  with  four  of  cold  water  for  an  application. 
Considerable  pain  is  likely  to  follow  the  application  :  a 
fresh  preparation  must  be  used  each  time. 

NITRATE  OF  SILVER.  Perhaps  no  remedy  has  been 
more  abused  in  gyncccological  practice  than  this.  Some 
of  the  most  inveterate  cases  of  ovaritis  that  I  have  seen 
have  been  the  result  of  persistent  cauterization  of  the 
cervix  with  lunar  caustic.  Since  the  profession  has 
become  acquainted  with  the  true  nature  of  the  so-called 
"ulcerated  cervix,"  and  found  it  was  in  reality  due  to  a 
laceration,  the  barbarous  treatment  of  "burning  the  ulcer 
out  "  has  largely  been  abandoned.  It  is  doubtful  whether 
it  should  ever  be  applied  to  the  cervix  if  there  is  ovaritis 
present.  Solutions  of  five,  and,  less  often,  ten  to  twenty 
grains  to  the  ounce,  will  be  found  helpful  in  stimulat- 
ing severe  erosions  to  healthier  granulation.  They  are 
touched  with  cotton  wrapped  on  a  wooden  stick,  the 
same  as  in  the  application  of  iodine.  The  cervix  is 
afterwards  dried  with  cotton,  a  tam.pon  smeared  with 
vaseline  pushed  up  against  it,  and  the  speculum  with- 
drawn. It  is  particularly  useful  in  vaginitis  of  a  viru- 
lent type.  In  these  cases  the  solution  should  be  applied 
through  the  Ferguson  or  cylindrical  speculum.  Pour  in 
a  teaspoonful  of  a  solution  of  twenty  grains  to  the 
ounce  (in  very  severe  cases,  half  a  drachm  to  the  ounce 
is  used  by  some  physicians),  and  as  the  speculum  is 
gently  withdrawn,  swab  the  vaginal  walls  thoroughly 
with  the  cotton-stick ;  when  the  tube  is  almost  out  of 
the  vagina,  depress  the  end,  and  allow  the  fluid  to  run 
out  in  a  cup.  Now  re-introduce  the  instrument,  and 
insert  a  long  cylindrical  tampon  well  smeared  with  vase- 


INDICATIONS  FOR  LOCAL   APPLICATIONS.    33 

line,  withdrawing  the  speculum  over  it.  This  silver 
solution  may  be  applied  once  a  week,  milder  ones  being 
used  as  the  case  improves.  It  is  hardly  necessary  to 
add  that  all  solutions  of  nitrate  of  silver  should  be  kept 
in  colored  glass,  and  protected  from  the  light. 

OPIUM  is  sometimes  added  to  applications,  for  its 
soothing  effect.  It  is  much  inferior,  however,  to  a  rec- 
tal suppository  containing  a  small  amount  of  the  drug. 

PINUS  CANADENSIS.  The  aqueous  extract  is  a 
popular  application  for  catarrhal  leucorrhoea,  endo-cer- 
vicitis,  and  a  relaxed  flabby  condition  of  the  vagina.  It 
is  essentially  an  infusion  of  hemlock-bark,  a  mild  astrin- 
gent, and  stains  linen  almost  indelibly. 

TANNIN  is  an  excellent  astringent  for  erosion  of  the 
cervix,  profuse  leucorrhoeal  discharge,  and  relaxation  of 
the  vaginal  wall  forming  cystocele  or  rectocele.  In  these 
latter  cases,  moisten  a  long,  slim  tampon  in  glycerine, 
or  smear  it  with  vaseline,  and  roll  it  in  finely  powdered 
tannin,  so  that  the  latter  will  come  in  contact  with  the 
entire  length  of  the  vagina  after  it  is  introduced.  In 
recent  sub-involution  of  the  vaginal  wall, — i.e.,  when 
it  follows  soon  after  confinement, — this  treatment  may 
prove  curative.  It  often  gives  great  relief  in  cases  of 
procidentia  refusing  an  operation.  Here  the  uterus 
must  be  replaced,  and  a  large  tampon  used,  supported 
by  a  T-bandage.  Instead  of  tannin,  I  have  sometimes 
used  a  strong  decoction  of  white-oak  bark,  or  a  dilution 
of  the  fluid  extract,  as  an  astringent  injection.  Matico 
might  be  preferable  to  either.  Dr.  Porter  recommends 
baycurn,  one  drachm  to  an  ounce  of  glycerine. 

The  use  of  severe  caustics,  such  as  nitric  acid,  per- 
nitrate  of  mercury,  bromine,  and  the  chloride  of  zinc,  has 
not  been  mentioned.  The  particular  point  to  be  ob- 
served in  their  use  is,  that  all  excess  of  fluid  must  be  very 


34  MINOR  SURGICAL   GYNECOLOGY. 

carefully  removed,  and,  as  a  rule,  the  surrounding  tissues 
protected  by  the  use  of  a  neutralizing  agent.  They  are 
very  rarely  called  for ;  and  the  physician  in  ordinary 
practice,  unless  expert  in  their  use,  had  better  leave 
them  entirely  alone.  The  worst  case  I  have  seen  of 
recto-vaginal  fistula  was  the  result  of  these  applications 
and  a  little  dripping  of  the  caustic  on  the  posterior 
vaginal  wall.  In  another  case,  a  tampon  was  saturated 
in  a  strong  solution  of  caustic  potash  and  applied  to 
the  cervix.  When  the  patient  rose  from  the  recumbent 
position,  some  of  the  fluid  ran  out,  causing  intense 
pain.  Sloughing  of  the  vagina  followed,  with  conse- 
quent cicatricial  contraction  so  that  a  No.  lo  catheter 
could  scarcely  be  passed  along  the  canal.  I  would 
earnestly  caution  any  one  against  their  use  who  is  not 
perfectly  familiar  with  the  details  of  their  application. 

The  proper  use  of  hot  water  is  almost  indispensable 
in  the  treatment  of  nearly  all  uterine  diseases.  The 
shrivelled  appearance  of  the  hand  after  soaking  it  in 
hot  water  is  familiar  to  every  one.  Its  action  on  the 
pelvic  tissue  is  similar,  —  decreasing  the  pelvic  conges- 
tion and  contracting  the  capillaries.  It  is  indicated, 
therefore,  in  all  inflammatory  and  hyperaemic  condi- 
tions, acute  or  chronic.  In  menorrhagia,  it  will  often 
arrest  the  flow.  Too  much  stress  cannot  be  placed  upon 
its  proper  administration,  which  will  be  given  in  some 
detail,  as  it  does  not  seem  to  be  thoroughly  understood 
by  all  the  profession.  As  a  rule,  it  should  be  given 
at  night  on  retiring,  but  some  cases  require  it  in  the 
morning  as  well.  It  is  almost  impossible  for  a  woman 
to  give  it  to  herself  with  the  same  benefit  she  would 
receive  with  proper  aid.  Much  better  results  will  be 
obtained  from  the  use  of  a  Davidson's  syringe  than  the 
fountain,'  although  it  is  much  more  difficult  to  use,  and 

I  Emmet,  Principles  and  Practice  of  Gynecology,  3d  ed.,  p.  117, 


THE   HOT-WATER   DOUCHE. 


35 


not  so  practicable  on  account  of  the  assistance  it  re- 
quires. Care  must  be  taken  that  the  nozzle  is  not 
made  of  metal,  as  the  latter  collects  the  heat  and  soon 
becomes  painful,  but  always  of  vulcanite  with  the  holes 
on  the  sides  of  the  tip,  and  without  a  perforation  in 
the'  point  of  the  tube.  Unless  the  patient  lies  on  a 
very  firm  mattress,  place  a  small  thin  board  under  her, 
'and  on  this  the  bed-pan  ;  otherwise,  when  the  patient's 
hips  rest  on  it,  one  side  of  the  pan  tilts  up  and  the  other 
sinks  down,  allowing  the  water  to  run  over  and  wet  the 
bed.     A  good  bed-pan  can  be  made  of  tin  with  a  rubber 


Fig.  i6.    Reynolds'  Siphon  Bed-Pan.      Fig.  17.    Reservoir  for  Vaginal  Douche. 

tube  attached  to  the  bottom  to  drain  off  the  water  as 
fast  as  it  collects,  into  a  pail  at  the  side  of  the  bed.  Her 
hips  should  be  elevated  two  or  three  inches  above  the 
level  of  her  shoulders,  to  have  the  aid  of  gravity  in 
emptying  the  pelvic  veins.  Not  less  than  six  quarts  of 
water  should  be  given  at  a  time,  as  hot  as  she  can 
bear  it,  with  the  bag  or  reservoir  of  water  two  or  three 
feet  above  the  patient,  and  the  injection  tube  well  up 
in  the  cul-de-sac  .  of  Douglas.  In  the  beginning  she 
may  not  be  able  to  bear  it  over  105°  F.,  but  it  can  soon 
be  increased  to  112°  F.  or  even  more.  The  hot-water 
douche  must  be  used  till  she  has  fully  recovered  ; 
towards  the  end  of  treatment  the  temperature  may  be 
lowered  to  75°  F.,  and  the  quantity  lessened  as  well. 


36  MINOR   SURGICAL   GYNECOLOGY. 

The  douche  should  be  given  daily,  except  during  two 
days  before  and  after  the  menses,  and  the  addition  of  a 
tablespoonful  of  glycerine  to  the  last  pint  of  water  is 
often  very  useful  to  increase  the  effect.  I  may  add 
here,  that  the  way  it  is  often  given  by  the  patient 
sitting  over  a  water-closet  amounts  to  nothing  more 
than  washing  out  the  vagina.  The  three  important,  or 
better,  essential  points  in  using  the  hot-water  douche 
are,  the  position  of  the  patient  (i.e.,  recumbent  with 
the  hips  elevated),  the  quantity,  and  temperature  of  the 
water ;  while  Dr.  Emmet  would  add  a  fourth,  a  David- 
son's instead  of  the  fountain  syringe. 

In  connection  with  the  hot-water 
douche,  it  may  be  well  to  refer  to 
another  method  of  applying  heat 
and  cold,  in  the  shape  of  hot-water 
or  ice  bags  to  the  spine,  which  was 
introduced  by  Dr.  Chapman.      In 

Fig.  i8.     Davidson's  Syringe.     pgj^J^  disOrdcrS,   either  the  hcat    Or 

the  cold  is  applied  to  the  spine  over  the  lower  dorsal 
and  lumbar  vertebrae. 

THE  ICE-BAG  is  Said  to  partially  paralyze  the  nerve- 
centres  or  ganglia,  and  lessen  the  nervous  currents  in 
the  vaso-motor  nerves  arising  from  them.  The  result 
is  that  the  blood-vessels  supplied  by  those  nerves  dilate, 
and  allow  an  increased  flow  of  blood  to  pass  through 
them.  The  ice-bag  has  been  used,  therefore,  for  sup- 
pressed, delayed,  and  scanty  menstruation  ;  and,  as  it 
has  been  useful  for  neuralgia,  it  may  prove  a  good  adju- 
vant in  treating  ovarian  neuralgia.  I  have  seen  great 
relief  follow  rubbing  the  spine  with  ice  in  attacks  of 
extreme  nervous  irritability  and  restlessness  verging  on 
nymphomania.  It  is  also  said  to  be  useful  to  control 
leucorrhcea. 


THE  SPINA  L  HO  T-  IV A  TER  BA  G.     PESSA  RIES.     3  7 

THE  HOT- WATER  BAG  (not  above  I20°  F.)  has  an 
opposite  effect,  and  is  supposed  to  stimulate  the  vaso- 
motor nerves.  The  arteries  contract,  and  the  supply  of 
blood  is  diminished.  It  has  proved  effectual  in  men- 
orrhagia  and  metrorrhagia  even  when  ordinary  local 
treatment  has  failed ;  and  ought  to  be  a  valuable  aid  in 
the  same  class  of  cases  as  those  requiring  the  hot- 
vi^ater  douche,  if  not  used  in  connection  with  it. 

The  mechanical  treatment  of  uterine  displacements 
has  been  warmly  discussed  among  physicians.  If  we 
compare  the  disputants,  it  is  noticed  that  the  specialists 
advocate  it,  while  those  less  familiar  with  the  subject 
condemn  it.  The  lesson  to  be  drawn  is  that  a  very 
large  proportion  of  practising  physicians  are  not  thor- 
oughly familiar  with  the  necessary  details,  and,  of 
course,  fail  to  obtain  good  results.  There  would  be 
quite  as  good  reason  for  objecting  to  splints  in  the 
treatment  of  fractures,  because  a  splint  suitable  for  a 
fractured  humerus  is  bandaged  on  the  thigh  in  a  frac- 
ture of  the  neck  of  the  femur,  and  the  case  left  to  nature 
without  extension  or  further  surgical  care.  No  one 
at  all  acquainted  with  surgery  would  expect  the  best 
possible  result. 

By  mechanical  treatment  is  meant  some  form  of 
uterine  support :  either  vaginal,  as  pessaries  ;  abdominal, 
in  the  shape  of  pads  or  belts ;  or  a  combination  of  the 
two.  It  has  a  distinct  place  in  gynaecology,  and  cer- 
tain rules  are  to  be  carefully  observed.  A  mere  tyro 
cannot  use  it  to  much  advantage ;  as  care,  a  knowledge 
of  what  is  needed,  and  how  to  apply  it  with  a  certain 
amount  of  mechanical  ingenuity,  are  essential. 

The  serious  objection  to  mechanical  treatment  is  that 
it  may  be  used  to  the  exclusion  of  all  other,  while  not 
infrequently  constitutional  or  local  treatment  at  the 
same  time  is  of  equal  importance. 


38 


MINOR  SURGICAL.  GYNAECOLOGY. 


The  most  important  factor  is  the  use  of  pessaries. 
The  varieties  of  these  are  almost  numberless,  as  not  a 
few  physicians  have  sought  to  immortalize  themselves 
by  making  some  instrument  of  slightly  different  shape, 
and  dubbing  it  with  their  names.  Space  forbids  any 
thing  like  an  enumeration.  The  principles  and  rules 
to  be  followed  in  using  them  are  the  same,  and  only 


Fig.  19.    Bow  Curved. 


Fig.  20.     Harding's. 


Fig.  21.    Hodge's. 


Fig.  22.     Smith's. 


Fig.  23.     Thomas'  Modification  of  Smith's. 


those  in  most  common  use  will  be  mentioned.  If  the 
reader  understands  these,  he  will  have  no  difficulty  in 
using  others. 

In  all  cases  where  the  pelvic  tissues  are  sensitive  to 
the  touch,  a  pessary  must  not  be  inserted.  It  would 
then  prove  a  source  of  irritation,  and  increase  the  in- 
flammation already  present.  It  is  absolutely  essential 
that  the  pessary  be  made  to  fit  perfectly  each  individ- 


HOW   TO  FIT  A   PESSARY.  39 

ual  case.  The  vaginas  of  different  women  vary  quite  as 
much  as  the  hands,  feet,  or  any  other  part  of  the  body. 
We  can  no  more  expect  all  gloves  to  fit  the  same  hand, 
than  all  pessaries  the  same  vagina.  It  is  this  fitting 
the  pessary  to  the  patient  which  measures  the  prac- 
titioner's success  in  using  it,  and  requires  the  most 
skill.  We  cannot  buy  fixed  sizes,  and  merely  select 
the  corresponding  one :  almost  always  some  cliange 
is  necessary.  In  order  to  ascertain  the  proper  size, 
the  uterus  must  be  replaced  ;  the  physician  can  then 
roughly  estimate  with  his  finger  the  length  and  breadth 
of  the  vagina,  the  depth  of 
the  posterior  cul-de-sac,  and 
breadth  of  the  vagina  behind 
the  pubes.  The  presence  of 
a  tender  spot  or  prolapsed 
ovary  should  be  noted.  This 
gives  an  approximate  idea  of 

what  is  wanted.  ^^^^^    Hopmann's  Pessahv. 

As  retro-displacements  are 
the  most  common,  they  will  be  considered  first.  In  the 
great  majority  of  cases,  a  carefully  adapted  Albert 
Smith  pessary  made  of  hard  rubber  will  be  the  best. 
In  some  cases  where  the  uterus  is  congested  and  sensi- 
tive, a  Hofmann's  soft  rubber  pessary  can  be  worn  tem- 
porarily with  relief  when  the  hard  rubber  cannot  be 
endured.  But  "a  fit"  must  be  had  first;  for  this  pur- 
pose, a  pessary  made  of  block  tin,  or,  preferably,  copper 
wire  covered  with  pure  gum  rubber,  should  be  used,  as  it 
admits  of  easy  moulding  or  bending  with  the  fingers,  and 
will  retain  the  shape  given  it.  One  of  these  is  selected 
according  to  the  measurements  taken  by  the  finger.  The 
posterior  portion,  which  occupies  the  cul-de-sac,  is  curved 
and  widened  according  to  the  depth  and  breadth  of  the 
latter,  and  the  height  to  which  the   uterus    is   raised. 


40  MINOR  SURGICAL   GYNAECOLOGY. 

This  is  ascertained  by  raistng  the  uterus  on  the  finger, 
to  a  position  that  is  comfortable  to  the  patient.  More 
than  this  should  not  be  done,  as  crowding  the  organ  up 
unduly,  interferes  with  the  circulation,  and  produces  the 
same  discomfort  as  when  it  sags  down.  It  should  be 
raised  enough  to  give  comfort,  and  allow  free  circula- 
tion without  torsion  or  compression  of  the  blood-vessels. 
The  upper  extremity,  i.e.,  the  posterior  portion,  of  the 
pessary,  should  be  rounded  to  press  up  between  the 
utero-sacral  ligaments.  In  some  cases  complicated  by 
prolapse  of  the  ovaries,  a  thickened  bu-lb-like  expansion 
of  the  posterior  portion,  or  a  square  instead  of  a  round 
shape,  is  preferable.  It  is  also  made  to  correspond  to 
the  width  of  the  vagina,  and  curved  so  that  the  anterior 
extremity  is  directed  toward  the  pubic  arch,  while  the 
tip  is  bent  downward  a  little  to  avoid  pressure  on  the 
urethra.  The  breadth  of  the  anterior  portion  depends 
on  the  amount  of  space  behind  the  pubic  arch.  Women 
who  have  given  birth  to  many  children,  and  whose 
vaginal  walls  are  relaxed,  require  as  a  rule  a  broader 
shape.  Should  there  be  some  tender  spot,  the  instru- 
ment must  be  moulded  so  it  will  not  press  upon  it. 

Having  replaced  the  uterus,  one  of  the  pessaries 
mentioned  is  bent,  or  moulded,  as  nearly  as  possible 
according  to  the  above  suggestions,  and  we  are  ready  to 
introduce  it.  Place  the  patient  on  her  left  side  in  Sims' 
position.  Thoroughly  oil  the  pessary,  and  hold  it  from 
the  convex  side  between  the  thumb  and  index  finger, 
the  tip  of  the  finger  on  the  inner  margin  of  the  broad  or 
posterior  end,  the  thumb  on  the  corresponding  outer 
margin.  Stand  a  little  behind  the  patient,  and  intro- 
duce the  pessary  edgewise  in  the  vulva,  pressing  it  well 
back  on  the  perineum.  When  about  two-thirds  of  the 
instrument  has  entered  the  vagina,  rotate  the  pessary, 
so  as  to  bring  the  convex  curve  posteriorly,  and  keep 


HOIV   TO   FIT  A    PESSARY.  4^ 

the  upper  end  crowded  well  back  against  the  posterior 
wall  by  the  index  finger,  which  is  kept  in  the  same 
place  on  the  pessary  ;  it  then  readily  glides  into  place 
behind  the  cervix.  This  last  is  important,  as  the  upper 
end  of  the  pessary  is  otherwise  very  apt  to  slide  up 
anterior  to  the  cervix,  and  cause  considerable  pain.  Its 
introduction  through  the  vulva  is  not  infrequently  pain- 
ful, but  once  in,  if  properly  fitted,  is  not  felt.  The 
anterior  end  is  then  placed  behind  the  pubic  arch  where 
it  naturally  lies,  and  is  kept  in  place  by  the  perineum. 
A  pessary  which  projects  in  the  least  from  the  vagina 
will  irritate  the  vulva,  and  is  not  a  proper  instrument. 
It  should  never  stretch  the  vaginal  wall,  and  the  tip  of 
the  finger  must  always  readily  pass  all  around  it,  ex- 
cept behind  the  cervix  where  it  is  out  of  reach,  but  undue 
stretching  will  at  once  be  detected.  Now  instruct  the 
patient  to  cough  or  bear  down  ;  if  this  does  not  dis- 
lodge it,  have  her  get  up,  walk  around,  cross  her  limbs, 
sit  down  in  a  low  chair,  etc.,  and  ask  her  whether  she 
can  feel  anything  anywhere  in  the  "  front  passage  ; " 
finally,  re-examine  to  see 'if  the  instrument  is  still  in 
place.  When  properly  adjusted,  it  will  not  be  dislodged, 
and  the  patient  is  not  able  to  feel  it.  If  it  slips  down 
in  any  way,  or  if  the  patient  can  detect  it,  it  does  not 
fit,  and  must  be  re-adjusted. 

Always  instruct  her  how  to  remove  it,  if  any  pain  is 
caused,  by  hooking  the  index  finger  into  it  behind  the 
pubes,  drawing  down  a  little  to  dislodge  it,  and  then 
steadily  upward  and  outward.  Be  careful  to  tell  her  that 
she  has  one  inserted,  and  if  of  soft  rubber  to  have  it  ex- 
amined once  a  month  ;  if  hard  rubber,  every  two  months. 
Tell  her  to  return  in  a  week.  If  she  has  found  it  the 
least  uncomfortable,  the  pessary  does  not  accurately  fit, 
and  the  necessary  changes  must  be  made  to  make  it  fit. 
If   she  has  been  unconscious  of  its  presence,  and  ex- 


42  MINOR  SURGICAL   GYNECOLOGY. 

perienced  great  relief,  the  fit  is  good,  and  it  should  be 
reproduced  in  hard  rubber,'  This  may  be  done  by  the 
instrument-maker;  but  not  every  physician  can  con- 
veniently send  the  block-tin  or  soft-rubber  model  pessary 
away,  and  he  must  mould  it  himself.  Carefully  remove 
the  one  inserted,  without  bending  it.  Select  another 
of  the  same  size  in  hard  rubber.  Smear  it  well  with 
vaseline,  and  heat  it  over  a  spirit-lamp,  or  an  ordinary 
kerosene  lamp,  till  the  rubber  softens,  then  mould  it 
into  exactly  the  same  shape  as  the  one  just  used,  and 
plunge  it  in  cold  water  for  a  couple  of  minutes  to  set  it. 
With  a  little  care,  the  fingers  will  not  be  burnt.  It  is 
introduced  in  the  manner  just  described.  These  pes- 
saries do  not  interfere  with  the  marital  relations.  Ste- 
rility depending  on  displacement  is  often  cured  by  this 
treatment. 

Anteversions  are  more  difficult  to  treat  than  retro- 
versions, Thomas'  open  cup,  Harding  anteversion, 
Grailly  Hewitt's,  Cutter's,  and  in  rare  cases  Gehrung's 
pessaries,  will  be  the  best  as  a  rule.  They  are  selected, 
introduced  in  a  similar  manner,  and  the  same  tests  are 
to  be  applied  to  these  as  to  the  former  ones.  Here,  of 
course,  the  fundus  is  to  be  lifted  up  in  front  of  the  cer- 
vix, and  the  cross-bar  or  rim  of  the  cup  lies  anterior  to 
the  uterus.  The  old  form  of  Thomas'  anteversion  pes- 
sary is  introduced  closed,  and  the  cross-bar  drawn  up  in 
place  by  a  silk  loop  previously  attached  to  it,  Ante- 
version pessaries  are  removed  by  drawing  on  the  rubber 
ring  lowest  in  the  vagina ;  the  last-mentioned  pessary 
closes,  and  the  open  cup  turns  over  in  extracting.  With 
the  exception  of  the  large,  hard  rubber  ring  for  prolap- 
sus, the  anterior  margin  of  which  rests  against  the  pubic 

'  The  soft  rubber  pessaries  soon  become  very  offensive,  but  can  be  readily 
disinfected  by  vifashing  thoroughly,  and  allowing  them  to  soak  a  few  hours  in  an 
ethereal  solution  of  iodoform. 


ANTE  VERSION  PESSA RIES. 


43 


arch,  and  the  posterior  up  on  the  posterior  vaginal  wall, 
the  ordinary  hard  rubber  and  elastic  ring  pessaries  will 
eventually  do  more  harm  than  good,  as  they  act  by  dis- 


FiG.[2S.    Thomas'  Ofen  Cup 
'!f6r  Anteversion. 


Fig.  26.     Thomas'  Anteversion  Pessary. 

An  older  and  often   inferior  instrument   to  the 

op^en  cup. 


Closed. 


Fig.  27.     Thomas'  Anteflexion. 


Open. 


F,G.28.  Thomas' A^JTEFLExioN  Pessary,     Fig.  29.    Gra.lly  Hewitt's  Anteversion 


WITH  Stem. 


Pessary. 


tending  and  stretching  the  vaginal  walls,  instead  of  the 
lever  action  exerted  by  the  various  modifications  of  the 
Hodge  pessary.     In  some  cases,  where  the  uterus  seems 


44 


MINOR  SURGICAL   GYNECOLOGY. 


to  be  perfectly  relaxed,  and  without  any  tone  whatever, 
becoming  retro-  or  anteverted  if  raised  from  either  posi- 
tion, the  intra-iiterine  stem  may  be  used  in  connection 
with  the  ordinary  pessary. 

In    all    cases   of   uterine  displacement,  a  well-fitting 
abdominal  bandage  or  supporter  is  a  great  help  by  tak- 


FiG.  30.     Cutter's  Ring  Pessary. 


(op  Thomaa*  Mod'  Cup. 

of  Loop. 

Fig.  31.     Gutter's  Pessaries. 


Fig.  32.     Donaldson's  Pessary. 


ing  off  the  weight  of  the  intestines.  For  the  same 
reason,  the  dress  and  skirts  should  hang  from  the 
shoulders.  A  retroversion  is  rarely  found,  where  the 
cul-de-sac  of  Douglas  is  very  shallow,  or  there  is  a 
lack  of  perineal  support.  Here  the  ordinary  vaginal 
pessary  is  of  no  use,  and  we  must  resort  to  a  vagino- 


ABDOMINAL   SUPPORTERS.  45 

abdominal  supporter,  or  cup  and  stem,  such  as  those 
of  Cutter  or  Thomas.  Macintosh's  supporter  is  also 
very  useful  in  many  of  these  cases.  All  pessaries 
having  an  external  support  are  a  great  annoyance  and 
source  of  irritation  to  the  patient,  who  will  endure  one 
for  the  simple  reason  that  it  is  the  lesser  of  two  evils. 

Most  of  the  abdominal  supporters  found  in  the 
market  are  constructed  on  false  principles,  being  con- 
cave to  conform  to  the  outward  curve  of  the  abdominal 
wall.  I  would  as  soon  think  of  applying  a  truss  curved 
to  fit  and  cover  a  hernial  sac,  as  such  a  supporter. 
The  latter  should  be  either  straight,  or,  better,  a  little 
convex,  so  as  to  press  the  abdominal  wall  gently  but 
firmly  upward,  and  a  little  inward  over  the  hypogastric 
region.  It  then  acts  as  a  kind  of  temporary  shelf  to 
keep  off  the  weight  of  the  intestines  and  pressure 
from  coughing,  straining  at  stool,  lifting,  etc.,  from  the 
contents  of  the  pelvis  below.  When  carefully  fitted,  I 
have  seen  great  relief  from  them,  not  only  in  uterine 
displacements,  but  also  in  various  acute  and 
chronic  inflammations  in  the  pelvis.  Not 
all  women  can  wear  an  abdominal  supporter. 
Those  with  broad  hips,  bulging  considerably 
between  the  trochanters  major  and  crests 
of  the  ilia,  are  best  adapted  to  them,  as  the  lakIe%^ubber 
supporter  is  not  likely  to  stay  well  in  place  proode'^ntia. 
on  a  straight-hipped  woman. 

I  have  had  the  most  satisfaction  from  an  inexpensive 
supporter,  which  can  be  made  by  any  ingenious  woman 
in  the  following  way.  The  patient  must  first  remove 
her  corsets,  loosen  all  the  clothing  above  the  hips,  and 
lie  down  with  the  pelvis  a  little  higher  than  her  shoul- 
ders, and  the  limbs  straight.  A  firm  linen  towel  is 
then  to  be  pinned  tightly  over  the  hips  next  to  the  skin, 
the  same  as  the  binder  after  confinement,  taking  care 


46,  MINOR  SURGICAL    GYNECOLOGY. 

that  it  is  perfectly  smooth,  and  the  lower  edge  an  inch 
and  a  half  below  the  trochanters.  This  holds  up  the 
abdomen,  and  affords  a  perfectly  smooth  surface  over 
which  a  pattern  of  firm  cotton  cloth  or  the  supporter 
itself  can  be  fitted.  The  latter  should  be  made  of  a 
piece  of  light-weight  but  firm  Russian  crash  about 
thirty-two  by  thirty-eight  inches,  i.e.,  wide  enough  to 
fold  double,  and  go  around  the  patient.  If  the  crash 
cannot  be  obtained,  a  firm  piece  of  drilling  is  a  good 
substitute.  Firmness  is  very  important,  and  for  this 
reason  flannel,  india-rubber  sheeting,  ordinary  cotton 
cloth,  etc.,  are  totally  unfit  for  the  purpose.  It  is  folded 
double,  not  merely  to  make  it  firmer,  but  especially  to 
have  all  seams  sewn  inside,  and  not  press  next  to  the 
skin.  This  is  fitted  smooth  and  tight  over  the  first 
binder  by  folding  over  the  upper  border  in  places,  and 
cutting  out  the  slack  cloth  in  the  hollow  of  the  back  in 
a  concave  line.  A  V-shaped  piece  an  inch  and  a  half 
wide  and  two  and  a  half  deep  is  cut  out  from  the  lower 
margin  over  each  trochanter,  and  a  couple  of  pieces  of 
strong  elastic  webbing  stitched  in.  This  keeps  it  snug, 
and  also  allows  more  motion  to  the  limbs.  Underneath 
each  gore  is  a  lappet  of  cloth  to  prevent  chafing  the 
skin.  Two  buttons  are  sewed  on  at  either  side,  to 
which  the  stocking-supporters  are  attached,  keeping  the 
supporter  from  slipping  up  on  the  hips.  Ten  or  a 
dozen  small  black  or  brass  buckles,  and  as  many  pieces 
of  firm  webbing  an  inch  wide  and  three  long,  are  sewed 
on  its  ends,  which  lap  over  in  front  and  a  little  to  the 
right  side.  This  allows  more  perfect  adjustment  to 
the  form.  In  some  ladies  the  ilia  project  anteriorly,  and 
the  abdominal  walls  are  so  thin,  they  would  not  receive 
sufficient  support  from  a  simple  binder.  In  these  cases 
a  pad  is  needed  corresponding  to  the  shape  of  the  hypo- 
gastrium,  and  thick  enough  to  exercise  gentle  pressure 


RULES  FOR    THE    USE   OF  PESSARIES,        47 

as  if  the  hand  were  there  holding  up  the  bowels.  If  the 
pad  be  thick,  curled  hair  is  the  best  material  ;  if  thin, 
a  folded  linen  napkin  answers  the  purpose.  This  pad 
or  cushion  should  be  separate  from  the  supporter,  and 
fastened  to  it  by  safety-pins.  This  allows  the  former 
to  be  washed,  and  by  having  two  or  three  extra  ones 
the  patient  can  wear  a  clean  supporter  as  often  as  she 
likes. 

Sometimes  three  or  four  may  have  to  be  made  before 
a  close-fitting  supporter  is  obtained,  which  stays  in 
place,  and  gives  comfort  to  the  wearer. 

It  is  not  uncommon  for  women  to  neglect  their  in- 
structions to  report  at  stated  intervals.  They  feel  so 
comfortable,  the  necessity  is  not  apparent,  or  they 
forget  it.  In  the  course  of  some  years  perhaps,  or 
less  time,  the  patient  calls  again ;  and  the  physician 
finds  the  pessary  so  embedded  that  it  is  very  difificult 
to  remove  it.  The  best  way  to  take  it  out  is  to  put 
the  patient  in  Sims'  position,  introduce  Sims'  speculum, 
divide  the  tissues  if  they  have  united  at  any  place 
over  the  pessary,  carefully  insert  the  director  or  probe 
beneath,  raise  it  up,  and  then  extract  it.  If  it  has 
merely  embedded  itself  in  the  tissues,  lying  in  a  sort  of 
groove,  pass  a  strong  silk  loop  through  the  anterior 
extremity  ;  as  this  is  gently  drawn  upon  with  one 
hand,  introduce  the  index  finger  up  behind  the  cervix, 
if  possible,  and  press  down  on  one  side  of  the  ring, 
thus  giving  it  a  little  twist,  so  as  to  dislodge  it  from 
the  groove,  and  from  behind  the  cervix. 

The  following  axioms  can  be  laid  down  for  the  use 
of  pessaries :  — 

1.  Never  introduce  a  pessary  if  inflammation  be 
present  in  any  portion  of  the  pelvis. 

2.  Always  replace  the  uterus  first. 

3.  Carefully  measure  the  vagina,  and  mould  the  pes- 


48  MINOR   SURGICAL   GYNECOLOGY. 

sary  to  it.      Never  introduce  the  instrument  with  the 
idea  of  allowing  the  vagina  to  conform  to  the  pessary. 

4.  Introduce  it  with  the  patient  lying  well  over  on 
her  left  side,  with  or  without  the  aid  of  Sims'  speculum. 

5.  Tell  your  patient  what  has  been  introduced  ;  in- 
struct her  how  to  remove  it  if  pain  is  caused,  and  to 
report  at  fixed  intervals. 

6.  If  the  cul-de-sac  of  Douglas  is  very  shallow,  it 
must  be  stretched  first  by  wearing  tampons,  or  no 
vaginal  pessary  will  stay  in  place,  neither  will  it  if  there 
be  no  perineal  support.  In  these  cases  a  Cutter's, 
Thomas',  or  Macintosh  pessary,  having  a  support  from 
an  abdominal  belt,  must  be  worn. 

7.  A  pessary  which  slips  down  between  or  projects 
from  the  vulva  is  displaced. 

8.  The  pessary  must  not  stretch  the  vagina,  but 
space  enough  always  be  left  to  sweep  the  tip  of  the 
finger  easily  around  it  next  to  the  vaginal  wall. 

9.  The  clothing  must  be  supported  from  the  shoulders. 

10.  Absolute  cure  by  merely  wearing  a  pessary  is 
the  decided  exception  to  the  rule.  Other  measures  are 
not  to  be  neglected. 

Dilatation  of  the  cervix  is  an  operation  which  the 
general  practitioner  is  sometimes  called  upon  to  per- 
form. It  may  be  gradual,  by  tents  ;  or  rapid,  by  in- 
struments for  dilatation  or  incision.  As  the  latter  is 
seldom  necessary,  and  is  more  of  an  operation  than  the 
former  methods,  it  will  not  be  considered  here. 

The  gradual  method,  by  tents,  is  a  favorite  with 
many.  The  tents  most  used  are  made  of  sponge, 
laminaria,  or  tupello.  Sponge  dilates  much  more 
rapidly  than  the  others,  but  requires  great  care  on 
account  of  the  danger  of  decomposition,  and  septic 
inflammation.     Its  meshes  penetrate  the  lining  of  the 


THE    USE    OF   TENTS.  49 

cervical  canal  to  a  certain  extent,  so  that  after  removal 
the  canal  is  somewhat  denuded,  and  the  distended 
glands  destroyed.  It  is  therefore  preferable  if  endo- 
cervicitis  is  present,  and  in  case  of  sub-involution  or 
hypertrophy  of  the  cervix,  the  surface  is  in  a  better 
condition  to  be  acted  upon  by  local  remedies.  Spieg- 
elberg  has  recommended  the  introduction  of  the  sponge 
tent  as  a  means  of  differential  diagnosis  between 
chronic  inflammation  or  sclerosis  of  the  cervix,  and 
incipient  cervical  cancer.  In  both,  the  tissue  might 
feel  hard  to  the  touch,  and  the  diagnosis  be  extremely 
difificult.  In  cancer,  the  tissue  would  be  firm  and  un- 
yielding, and  comparatively  unaffected  by  the  sponge 
tent,  while  in  hyperplasia  it  would  be  softened  and 
relax.  Should  experience  confirm  this  as  a  reliable 
test,  it  would  become  a  valuable  aid  in  establishing 
the  diagnosis. 

Laminaria,  or  sea-tangle,  requires  much  more  time 
to  dilate,  and  is  more  powerful  than  sponge.  It  does 
not  expand  as  much  in  proportion  to  its  size,  but  there 
is  much  less  danger  of  decomposition. 

Tupello  tents  unite  the  advantages  of  the  preceding 
ones,  and  expand  very  evenly.  With  the  exception  of 
the  cases  mentioned  under  sponge  tents,  tupello  is  pref- 
erable to  either  sponge  or  laminaria.  Sponge  tents 
expand  more  than  the  others,  about  three  times  their 
diameter ;  laminaria,  not  quite  twice ;  while  tupello 
enlarges  to  fully  twice  their  size.  Sponge  and  tu- 
pello swell  in  about  twelve  hours  ;  laminaria  requires 
eighteen  or  twenty.  Dr.  Emmet  has  found  tents  made 
from  the  pith  of  cornstalks  excellent  to  exercise  an 
alterative  effect  on  the  lining  membrane,  and  also  to 
apply  iodine  to  the  cervical  canal  by  immersing  the 
tent  just  before  introducing  it  into  the  canal.  They 
have,  however,  very  little  dilating  power. 


5Q  MINOR  SURGICAL   GYNECOLOGY. 

Dilatation  of  the  cervical  canal  is  indicated  when 
there  is  not  a  free  exit  for  fluids  from  the  uterine  cavity, 
as  in  dysmenorrhoea,  associated  with  a  long,  small  canal, 
a  constriction,  or  some  flexure  in  it ;  when  there  is 
not  a  free  entrance  to  the  uterine  cavity,  for  the  same 
causes,  that  render  local  applications  very  difficult  or 
impossible,  and  is  not  unfrequently  associated  with 
sterility  ;  and,  finally,  in  cases  needing  a  digital  exam- 
ination of  the  cavity,  such  as  fibroids,  polypii,  retention 
of  placenta,  or  a  dead  foetus.  All  tents  are  introduced 
in  the  same  way.  Sponge  requires  more  celerity,  as  it 
swells  rapidly,  and  the  sides  roughen,  which  increase 
the  difficulty.  As  with  the  sound  and  pessaries,  tents 
must  not  be  used  if  any  inflammation  is  present  ;  con- 
trary to  the  former,  however,  it  must  be  an  invariable 
rule  never  to  introduce  a  tent  at  the  office,  but  always 
at  the  house.  The  danger  of  subsequent  inflammation, 
though  slight,  is  too  great  to  take  any  additional  risk 
by  departing  from  the  above  rule.  The  patient  should 
remain  in  bed  from  the  time  of  introduction  till  thirty- 
six  or  forty-eight  hours  after  removal  of  the  tent.  This 
may  seem  a  needless  caution  in  many  cases,  but  an 
ounce  of  prevention  sometimes  saves  many  a  pound  of 
cure. 

Before  introducing  the  tent,  direct  the  patient  to  take 
a  five-per-cent  carbolized  vaginal  douche.  Without  any 
delay  place  her  in  Sims'  position.  A  bivalve  speculum 
may  be  used,  but  Sims'  is  preferable.  After  exposing  the 
cervix,  seize  the  anterior  lip  with  a  tenaculum,  and  draw 
it  down  a  little  to  straighten  the  canal  and  steady  the 
uterus.  Probe  the  canal  carefully  to  ascertain  its  direc- 
tion and  probable  size.  If  any  blood  escapes  afterward, 
wait  twenty-four  hours,  when  there  are  no  urgent  symp- 
toms calling  for  dilatation.  Otherwise,  select  a  tent 
which   will  readily  enter  the   canal,  and   pass   through 


THE    USE    OE   TENTS. 


51 


the  internal  os.  \  common  mistake  is  to  choose  a  tent 
which  fits  too  tight ;  during  the  efforts  of  introduction 
it  swells,  and  increases  the  difficulty.  This  is  particu- 
larly true  of  sponge  tents.  Seize  the  base  of  the  tent 
firmly  in  the  dressing  forceps,  or  impale  it  on  a  tent 
carrier,  taking  care  not  to  entangle  the  latter 
with  the  twine,  bury  it  in  a  pot  of  carbolized 
vaseline,  and  insert  it  quickly  in  the  canal. 
Do  not  allow  the  tip  of  the  tent  to  touch  the 
fundus,  or  it  will  be  forced  out  by  uterine 
contraction.  It  should  just  enter  the  uterine 
cavity,  and  that  is  all ;  i.e.,  only  about  an  inch 
and  a  half  or  three-quarters  should  be  intro- 
duced. Sometimes  the  finger  must  hold  it 
in  place  till  a  couple  of  fiat  cotton  disks,  satu- 
rated in  glycerine,  can  be  placed  against  it 
to  insure  retention.  The  speculum  is  then 
carefully  withdrawn. 

Sponge  and  tupello  tents  may  be  left  for 
twelve  hours,  laminariafor  eighteen  or  twenty. 
All  tents  are  inserted  in  the  same  way.  When 
laminaria  tents  are  preferred,  and  considerable 
dilatation  is  desired,  several  small  ones  may 
be  introduced,  one  beside  another,  forming  a 
little  bundle  or  fagot. 

In  removing  a  tent,  put  the  patient  in 
Sims'  position,  introduce  the  speculum,  seize 
the  projecting  tent  with  the  dressing  forceps, 
give  a  little  twist  to  loosen,  and  then  with- 
draw it,  making  counter  pressure  at  the  same  time  with 
the  fingers  of  the  other  hand  on  the  cervix.  As  con- 
siderable force  is  sometimes  necessary,  it  is  not  wise  to 
direct  the  patient  to  remove  it  by  the  loop  of  twine. 
The  operator  can  now  make  a  digital  examination  of 
the  cavity,  remove  the  polypus,  incise  the  capsule  of  a 


52  MINOR  SURGICAL   GYNECOLOGY. 

fibroid  tumor,  use  the  curette,  or  accomplish  whatever 
was  the  object  of  dilatation. 

The  cavity  should  be  cleansed  afterward  with  a  three- 
per-cent  solution  of  carbolic  acid,  and  calendula  cerate 
(made  from  petrolatum  or  vaseline)  freely  applied  to  the 
upper  portion,  which  will  bathe  the  lower  as  it  melts 
and  runs  down.  Though  I  have  not  had  occasion  to 
use  it,  I  believe  the  addition  of  enough  muriate  of 
cocaine  to  the  calendula  cerate,  to  make  it  four  per 
cent,  would  be  excellent  to  allay  the  irritation.  A  dry 
tampon  can  then  be  placed  agai'nst  the  cervix,  or,  if  a 
serous  discharge  is  desired,  it  is  soaked  in  glycerine, 
and  the  speculum  withdrawn.  The  patient  must  be 
particularly  careful  to  avoid  exposure  to  cold,  and  re- 
main in  bed  till  all  soreness  has  ceased. 

Anaesthesia  is  not  necessary  for  the  introduction  or 
removal  of  a  tent.  The  dilatation  necessarily  causes 
some  pain,  and  it  is  customary  to  insert  a  rectal  sup- 
pository of  one-fourth  grain  of  morphine  when  the  tent 
is  introduced. 

Where  dilatation  is  undertaken  for  dysmenorrhoea, 
sterility,  etc.,  also  in  some  relaxed,  flabby  conditions  of 
the  uterus,  stems  of  hard  rubber  or  glass  (Wylie's  or 
Thomas')  are  inserted  afterward  to  insure  a  patulous 
canal,  or  straighten  the  organ,  as  the  canal 
is  liable  to  contract  again,  and  may  re- 
FiG.        Galvanic  ^uirc  two  or  three  dilatations  to  insure 

Stem  Pessary.  ^^^  permanent  cffcct.  Galvauic  stems 
made  of  alternate  beads  or  plates  of  zinc  and  copper 
are  also  worn  for  amenorrhoea  and  defective  develop- 
ment of  the  uterus. 

The  same  rules  for  the  use  of  tents  apply  to  stem 
pessaries,  except  the  latter  are  more  permanent,  and 
should  be  removed  during  the  menstrual  period,  or  if 
the  least  pain  is  experienced  from  them.     If  the  fundus 


RULES  FOR    THE    USE   OF   TENTS.  53 

tips  forward,  the  base  of  the  stern  rests  against  the 
vaginal  wall,  and  is  self-retaining;  but  when  the  fundus 
lies  sufficiently  backward  to  direct  the  stem  toward  the 
axis  of  the  vagina,  the  instrument  will  drop  out,  unless 
supported  by  a  cup-shaped  pessary  made  for  that  pur- 
pose. 

The  following  rules  should  be  observed  in  the  use  of 
tents : — 

1.  Always  introduce  the  tent  at  the  patient's  house, 
and  keep  her  in  bed  from  that  time  till  thirty-six  hours 
after  its  removal.  In  very  exceptional  cases,  she  may 
leave  her  bed  in  twenty-four  hours. 

2.  Never  introduce  a  tent  if  there  is  any  sensitive- 
ness or  soreness  in  the  pelvis,  or  pregnancy  suspected. 

3.  Use  careful  antiseptic  precautions. 

4.  Never  follow  one  sponge  tent  immediately  by  an- 
other, or  introduce  a  sponge  tent  against  a  wounded 
surface. 

5.  Remove  sponge  and  tupello  tents  in  twelve  hours, 
laminaria  in  twenty  at  the  latest. 

6.  Be  careful  in  every  detail,  and  do  not  be  afraid  of 
too  much  precaution.  Serious  results  have  sometimes 
followed  this  operation. 

By  rapid  dilatation  is  meant  the  performance  of  the 
operation  at  one  sitting,  lasting  half  an  hour  if  neces- 
sary, but  usually  in  much  less  time.  It  may  be  accom- 
plished by  a  series  of  carefully  graduated  sounds,  or  the 
diverging  blades  of  some  instrument  within  the  cervical 
canal.  The  best  examples  of  the  former  are  the  hard 
rubber  bougies  of  Hegar,  about  eighteen  in  number,  for 
ordinary  purposes,  and  ten  or  twelve  more  up  to  a  diame- 
ter of  twenty-six  millimetres  when  unusual  dilatation  is 
required.  The  smallest  is  about  the  size  of  a  fine  probe, 
and  the  succeeding  numbers  increase  one-half  a  milli- 
metre respectively.     Professor  Fritsch  of  Breslau  uses 


54 


MINOR  SURGICAL   GYNECOLOGY. 


steel  sounds  of  similar  gradation.  They  can  be  used 
through  the  speculum,  the  cervix  being  seized  by  vol- 
sellum  forceps  for  counter  pressure,  or  introduced  like 
the    sound    without   the   speculum,    the    hand    outside 


crowding- the  fundus  down  on  the  dilator  like  a  glove 
over  the  finger.  This  latter  method  is  recommended 
by  Professor  Fritsche.  I  have  never  tried  it,  but  be- 
lieve it  more  theoretical  than  practical  for  the  general 
practitioner. 


OPERATION  OF  RAPID   DILATATION.  5  5 

For  a  minor  degree  of  dilatation  of  a  very  small  cer- 
vical canal,  these  graduated  bougies  serve  an  excellent 
purpose,  but  as  a  rule  too  much  force  is  necessary  where 
many  are  introduced,  and  I  prefer  to  use  an  instrument 
with  diverging  blades. 

Dr.  Goodell  is  a  zealous  advocate  for  rapid  dilatation 
of  the  cervix  uteri,  and  has  done  much  to  bring  it  into 
notice  in  this  country.' 

The  Ellinger  dilator,  as  recently  modified  by  him,  is 
an  admirable  instrument  for  this  purpose,  but  is  much 
more  expensive  than  Wylie's  modification  of  Sims',  which 
is  a  popular  instrument.  The  latter  is  better  adapted  to 
cases  of  acute  anteflexion  of  the  uterus.  The  former  is 
made  in  two  sizes,  the  smaller  for  use  in  very  small 
canals,  while  the  larger  is  much  more  powerful.  The 
smaller  instrument  can  be  used  for  a  minor  degree  of 
dilatation,  —  i.e.,  upto  a  quarter  of  an  inch,  —  at  the  office 
without  anaesthesia,  or  to  prepare  the  way  for  the  larger 
one. 

For  thorough  dilatation  the  patient  must  be  anaesthet- 
ized, and  just  before  the  operation  a  suppository  con- 
taining one  grain  of  the  watery  extract  of  opium  is 
inserted  into  the  rectum.  She  is  then  placed  on  her 
back  or  side  in  a  good  light,  a  speculum  introduced, 
and  the  vagina  swabbed  or  irrigated  with  a  five-per-cent 
solution  of  carbohc  acid.  The  cervix  is  seized  with 
a  strong  tenaculum,  and  if  the  larger  Ellinger  dilator 
will  not  enter  the  cervical  canal,  the  smaller  one  is 
introduced  as  far  as  it  will  go,  the  blades  separated 
a  little  for  a  moment,  then  closed,  and  slipped  a  little 
farther  in,  and  the  same  process  repeated  till  the  os 
internum    is   passed.     The  handles  are  now  gradually 

'  Goodell's  Lessons  in  Gynaecology,  p.  149.  Transactions  Philadelpliia  Obstet- 
rical Society,  1878.  For  operation  and  statistics  in  dysmenorrhoea  and  sterility, 
see  lecture  by  Professor  Goodell  in  the  Medical  News,  Dec.  12,  i88j. 


56  ,  MINOR  SURGICAL   GYNECOLOGY. 

brought  together,  and  held  there  for  a  couple  of  min- 
utes. This  dilator  is  withdrawn,  and  replaced  by  the 
larger  one ;  the  handles  are  slowly  screwed  together 
until,  according  to  Dr.  Goodell,  the  scale  shows  a  dilata- 
tion of  an  inch  to  an  inch  and  a  half.  Many  operators 
do  not  care  to  dilate  over  three-quarters  of  an  inch,  and 
think  half  an  inch  enough  for  the  majority  of  cases. 
The  margin  of  the  cervix  must  be  watched  for  any 
laceration,  which  rarely  happens.  If  there  is  marked 
flexion  in  the  canal.  Dr.  Goodell  recommends  the  dila- 
tor to  be  introduced  with  its  curve  in  the  opposite 
direction  to  the  flexion,  without  rotating  the  uterus, 
and  the  final  dilatation  to  be  then  made.  After  the 
necessary  degree  of  expansion  is  reached,  the  ether  is 
withdrawn,  and  the  dilator  kept  in  place  for  about 
fifteen  minutes,  when  it  is  closed,  removed,  and  the 
vagina  again  irrigated.  The  after-treatment  is  the  same 
as  for  tents.  If  the  case  was  one  of  retroversion  or 
flexion,  it  would  be  well  to  use  a  carefully  adjusted 
pessary  for  a  short  time.  In  some  cases  of  pin-hole  os 
externum  the  small  dilator  will  not  enter,  and  the  os  may 
be  nicked  or  forced  open  by  the  boring  motion  of  the 
closed  points  of  a  pair  of  straight  scissors.  In  rare  cases, 
it  is  necessary  to  repeat  the  operation,  but,  as  a  rule,  the 
canal  does  not  return  to  its  former  condition.  A  slight 
discharge  of  blood  may  follow  the  operation  for  a  few 
days,  and  the  patient  must  remain  in  bed  till  all  soreness 
has  subsided.  The  middle  of  the  inter-menstrual  period 
for  dysmenorrhoea,  or  in  the  last  third  for  sterility,  is 
the  best  time  to  operate.  Very  excellent  results  will  be 
obtained  in  some  cases  of  dysmenorrhoea,  but  not  so 
much  can  be  hoped  for  in  sterility. 

Rapid  dilatation  is  much  more  effectual  than  by  tents, 
but  patients  will  not  always  consent  to  an  operation. 
It  is  preferable  to  gradual  dilatation  in  cases   of  menor- 


THE    USE   OF  THE   CURETTE. 


57 


this 


rhagia,  depending  on  retained  secundines,  polypus,  etc., 
where  the  cervical  tissue  is  soft  and  relaxed,  admitting 
of  easy  expansion.  The  canal  may  also  be  stretched 
for  the  use  of  the  curette,  or  irrigation  of  or  applications 
to  the  cavity. 

The   use   of   the    curette   deserves    mention    in 
chapter,  as  the   operation    is    not    infrequently 
necessary,  can  be  easily  performed  with  proper 
care,    and    is    generally   followed    by   excellent 
results.     The  counter-indications  are  the  same 
as  for  the  sound,  pessaries,  tents,  etc.     The  one 
main  indication  is  a  persistent  metrorrhagia  in 
spite  of  carefully  selected  remedies.     This  may 
depend  on  retention  of  a  portion  of  the  placenta, 
as  after  an  abortion  at  about  the  fourth  month  5 
of  gestation,  fungoid  degeneration  of  the  endo-  ^ 
metrium,  and  diffuse  sarcoma  of  the  mucosa  of  h 
the  uterine  cavity,  which  is  so  rare  that  very  few  § 
physicians  meet  with  it.     Sims'  sharp  curette,  '"- 
with  a  stiff  shank,  will  be  necessary  to  remove  | 
enlarged  Nabothian  follicles,  in  severe  cases  of  ^ 
endo-cervicitis.  S 

For  most  cases  the  dull  wire  curette  is  the  .w 
best   to  use,   and  the  least  likely  to  do  harm. 
After  the  usual  antiseptic  irrigation  with  a  five- 
per-cent    solution   of   carbolic    acid,   or   one   in 
four  thousand  of  corrosive  sublimate,  the  patient 
should  be  placed  in  Sims'  position,  Sims'  specu- 
lum inserted,  the  cervix  seized  with   a  strong 
tenaculum,  or  volsellum  forceps,  and  drawn  a 
little  forward  to  straighten  the  canal.     The  dull 
curette  is  now  introduced  to    the   fundus,   and    drawn 
downward  and  outward,  going  over  the   entire   cavity 
in  routine  order,  so  as  not  to  miss  any  portion.     It  is 
then  irrigated  with  warm  carbolized  water,  io8°-i  10°  F., 


3 


58.  MINOR  SURGICAL   GYNECOLOGY. 

taking  care  there  is  a  free  escape  for  the  fluid  through 
the  OS.  If  there  is  any  bleeding  after  this,  the  cavity 
can  be  swabbed  out  with  pure  tincture  of  iodine  applied 
on  cotton,  wound  over  the  probe,  and  afterwards  two 
or  three  tampons  crowded  against  the  cervix  to  insure 
against  hemorrhage. 

Should  this  fail  to  arrest  bleeding,  half  a  drachm  of 
iodine  can  be  injected  into  the  cavity  with  a  Buttle's 
syringe,  after  irrigating  the  uterus  with  hot  water  (112°), 
If  bleeding  continues  in  spite  of  this,  a  one  to  four  or 
even  stronger  solution  of  the  persulphate  of  iron  can  be 
used,  which  is  the  routine  practice  of  Dr.  A.  Martin. 
The  iodine  is  usually  effectual,  however,  and  is  much 
safer  than  the  iron.  With  either  drug  great  care  must 
be  taken  to  secure  a  patulous  canal,  and  prevent  any 
forcing  of  the  fluid  through  a  Fallopian  tube  by  a  sudden 
contraction  of  the  uterus. 

Anaesthesia  is  rarely  necessary,  but  the  patient 
must  be  enjoined  to  remain  in  bed  while  there  is  any 
pelvic  soreness.  In  exceptional  cases  the  dull  wire 
curette  is  not  firm  enough  to  remove  the  polypi  or 
adherent  bits  of  placental  tissue.  In  these  cases  I 
have  used  Recamier's  curette  with  much  satisfaction. 
The  scraping  action  of  this  instrument  is  around  the 
uterus  rather  than  from  above  downward  :  otherwise, 
the  operation  is  performed  in  the  same  way,  but  with 
either. 

The  use  of  Simon's  sharp  spoon  curette,  with  inflexi- 
ble shank,  is  restricted  almost  entirely  to  the  removal 
of  cancerous  masses,  and  is  too  formidable  an  opera- 
tion to  be  given  in  a  brief  resume  of  minor  surgical 
gynaecology. 


DISEASES  OF   THE    URETHRA.  59 


CHAPTER    III. 

DISEASES    OF    THE    URETHRA. 

UNFORTUNATELY  there  is  not  much  accurately 
and  positively  known  about  these  diseases  by  the 
majority  of  the  profession,  and  reflex  neuroses  are 
sometimes  so  prominent  as  easily  to  mislead  the  phy- 
sician in  his  diagnosis.  Fissure  of  the  anus  has  caused 
decided  symptoms  of  cystitis.  Malposition  of  the 
uterus,  or  disease  of  the  pelvic  organs,  such  as  cellulitis 
of  the  utero-sacral  ligaments,  are  common  causes  of 
dysuria,  and  therefore  liable  to  cause  error  in  diagnosis. 
Many  a  woman  has  been  treated  for  cystitis,  when  only 
the  urethra  was  affected. 

Disease  of  the  urethra,  on  the  other  hand,  may  give 
rise  to  various  reflex  phenomena,  such  as  vaginismus, 
chorea,  or  even  epileptiform  convulsions.' 

The  most  common  of  the  diseases  under  considera- 
tion are  the  following  :  — 

Vascular  or  neuromatoid  growths. 

Prolapse  of  the  mucous  membrane  or  urethra. 

Laceration  of  the  urethra,  or  fissures  at  the  neck  of 
the  bladder. 

Inflammation  of  the  urethra,  i.e.,  urethritis. 

The  vascular  or  neuromatoid  growths  may  be  flat  or 
pedunculated,  more  often  the  latter,  and  closely  resem- 
ble a  polypus.     They  are  very  vascular,  bleed  easily, 

'  A  curious  case  of  this  kind,  which  was  cured  by  an  operation,  is  recorded  in 
Emmet's  Principles  and  Practice  of  Gynascology,  3d  ed.,  p.  759. 


6o  DISEASES  OF  THE    URETHRA. 

and  are  exquisitely  sensitive.  As  a  rule,  only  one  is 
present,  but  there  may  be  more,  varying  in  size  from  a 
small  pea  to  a  large  cherry.  Although  the  favorite 
seat  is  at  the  external  meatus,  they  may  be  found  in 
any  part  of  the  canal. 

The  chief  symptoms  are,  pain  in  the  urethra  on 
touching  it,  pain  when  walking,  and  agonizing  pain  on 
voiding  urine,  particularly  the  last  few  drops.  This  last 
symptom  is  the  most  important,  and  may  lead  to  a 
suspicion  of  stone  in  the  bladder  ;  but  in  this  case  the 
pain  is  less  acute,  and  more  like  a  deep-seated  aching 
or  sore  pain.  There  is  not  infrequently  present  much 
reflex  irritation  of  the  bladder,  uterus,  vagina,  or 
rectum. 

The  diagnosis  is  easy  if  the  growth  is  seen  in  the 
orifice  of  the  urethra  on  parting  the  labia,  but  when  it 
lies  concealed  in  the  urethral  canal  it  is  not  so  simple 
a  matter.  In  the  former  case,  the  excessive  sensitive- 
ness to  touch  will  distinguish  it  from  other  conditions, 
such  as  syphilitic  excrescences  or  partial  prolapse  of  the 
urethral  mucous  membrane.  If  the  dysuria  cannot  be 
accounted  for  in  any  other  way  by  careful  examination, 
the  urethra  may  be  opened  by  Emmet's  method,  and  the 
mucosa  exposed.  It  is  neither  difficult  nor  dangerous, 
and  in  no  other  way  can  the  same  amount  of  informa- 
tion be  obtained. 

The  local  treatment  in  all  these  cases  is  essentially 
the  same,  wherever  the  growth  is  found.  It  may  be 
removed  with  scissors  or  fine  forceps,  and  the  base 
touched  with  an  actual  cautery  or  the  point  of  a 
sharpened  match  dipped  in  nitric  acid,  which  is  imme- 
diately neutralized  by  applying  a  piece  of  cotton  soaked 
in  a  solution  of  bicarbonate  of  soda. 

As  little  tissue  as  possible  should  be  removed  or  cau- 
terized, as  the  resulting  cicatrix  is  liable  to  contract, 


URETHROCELE.  6l 

diminish  the  calibre  of  the  canal,  and  in  time  cause 
cystitis.  These  growths  are  prone  to  return,  though  the 
greatest  care  may  have  been  taken  in  their  removal. 

If  the  urethra  has  been  opened,  and  the  mucosa  is 
perfectly  healthy,  excepting  the  polypoid  growth,  it 
may  be  closed  at  once,  as  soon  as  the  excrescence  is 
destroyed  ;  otherwise,  it  is  better  to  wait  till  the  mucous 
membrane  is  in  a  normal  state,  and  close  it  in  the 
same  way  as  an  ordinary  fistula.  If  the  growth  is  large, 
has  a  broad  base,  and  is  very  vascular,  it  is  better  to 
ligate  it  to  prevent  hemorrhage,  which  is  sometimes 
excessive.  Immediate  removal  followed  by  the  remedy 
is  far  better  than  to  reverse  the  order  in  treatment. 

Prolapse  of  the  mucous  membrane  or  urethra  is  read- 
ily recognized.  The  symptoms  are  very  similar  to 
those  just  given  for  excrescences  of  the  urethra,  but  the 
dysuria  is  not  as  severe.  The  diagnosis  of  urethrocele 
is  easy  from  the  rolling-out  of  the  mucosa  at  the  meatus. 
It  is  not  as  sensitive  as  a  growth,  has  no  pedicle,  and  can 
be  reduced  with  a  large  sound.  It  may  form  a  complete 
circle  around  the  urethra,  or  project  from  one  side,  more 
especially  the  anterior  wall.  The  history  of  the  case 
usually  dates  from  child-bearing. 

The  treatment  of  these  cases,  until  quite  recently, 
was  to  excise  or  cauterize  the  prolapsed  tissue.  The 
results,  however,  are  seldom  permanent,  and  in  a  few 
months  the  patient  is  often  as  bad  as  before. 

The  best  plan  is  to  incise  the  urethra  from  the  vaginal 
surface,  draw  out  the  slack  -membrane  through  the 
opening  till  all  the  urethrocele  has  disappeared,  insert 
silver  sutures,  cut  off  the  superfluous  tissue,  and  close 
the  wound.  The  operation  for  prolapse  of  the  urethra 
is  somewhat  similar,  the  object  being  to  denude 
enough  longitudinally  in  the  incision  to  make  the  ure- 
thral canal  of  the  same  calibre  throughout  and  prevent 


62  DISEASES   OF   THE    URETHRA. 

the  formation  of  any  pouch  for  the  accumulation  of 
urine. 

The  diagnosis  of  fissures  at  the  neck  of  the  bladder 
must  be  made  chiefly  by  exclusion,  as  there  are  no 
characteristic  symptoms  peculiar  to  this  lesion,  which 
cannot  be  found  in  other  affections  such  as  the  early 
stages  of  cystitis.  If  internal  remedies  fail,  the  produc- 
tion of  a  vesico-  or  urethro-vaginal  fistula  is  necessary 
to  give  the  muscular  tissue  rest.  Dilatation  of  the  ure- 
thra has  also  been  recommended,  and  is  said  to  be  very 
beneficial  for  spasm  of  the  bladder.'  It  is  worth  bearing 
in  mind  for  chronic  cases  where  remedies  fail  to  relieve. 

Laceration  of  the  vesical  opening  of  the  urethra,  as 
the  result  of  dilatation,  is  an  obstinate  and  almost  incur- 
able affection.  It  is  characterized  by  incontinence  of 
urine.  As  the  treatment  of  this  lesion  is  surgical,  and 
not  likely  to  be  of  interest  to  the  general  practitioner,  the 
reader  is  referred  to  Emmet's  article  on  the  subject.'' 

Urethritis,  either  acute  or  chronic,  is  often  the  result 
of  gonorrhoeal  infection  :  under  these  circumstances,  it 
must  be  treated  similarly  to  gonorrhoea  in  the  male. 
The  thick  yellow  pus  which  can  be  pressed  from  the 
meatus  by  compressing  the  urethra  from  above  down- 
wards with  the  tip  of  the  finger  on  the  vaginal  surface 
is  characteristic  of  gonorrhoea.  Urethritis  may  also 
result  from  traumatism,  or  exposure  to  cold.  The  his- 
tory of  the  case,  frequent  and  painful  micturition,  with 
heat  and  burning  in  the  parts,  will  be  sufficient  for  a 
diagnosis.  The  chemical  and  microscopical  examina- 
tion of  the  urine  should  not  be  omitted.  Injections 
must  be  employed  with  caution,  lest  the  discharge,  if 
any,  be    driven    into    the    bladder,  and    cystitis  result. 

'  See   Emmet,    Principles  and  Practice  of  Gynxcology,  3d  ed.,  pp.  743,  751, 

757- 

2  Ibid,  p.  763. 


TREATMENl^  OF   URETHRITIS.  63 

Perfect  rest,  tepid  sitz-baths,  and  bathing  the  parts 
several  times  a  day,  are  essential.  If  the  physician  is 
desirous  of  making  a  local  application,  the  extract  of 
pinus  canadensis,  with  the  addition  of  a  little  impure 
carbolic  acid,   may  be  tried. 

Another  excellent  application  is  a  cerate  of  hydrastis, 
calendula,  or  iodoform  :  the  former,  if  the  discharge  is 
of  a  catarrhal  nature  ;  calendula,  if  the  disease  occurs 
in  the  puerperal  state  and  the  discharge  is  purulent, 
which  may  be  due  to  the  presence  of  some  laceration  or 
linear  ulcer  ;  while  iodoform  is  better  for  the  chronic 
than  acute  stages.  The  cerate  may  be  applied  by  wind- 
ing a  little  cotton  over  a  probe,  and  smearing  it  with 
the  proper  ointment.  It  is  then  introduced  within  the 
urethra,  and  allowed  to  remain  for  a  few  minutes.  The 
same  remedies  may  be  applied  in  solution  with  a  syr- 
inge. Neither  is  so  neat,  however,  as  to  introduce  a 
slender  gelatine  suppository,  properly  medicated,  which 
is  retained  by  the  bulbous  expansion  of  its  point,  and 
allowed  to  dissolve.  An  injection  of  a  four  per  cent 
solution  of  cocaine  has  also  been  used  for  temporary 
relief  from  distressing  tenesmus. 

The  diet  should  consist  of  simple,  wholesome  food, 
without  condiments.  Milk  is  the  best  drink.  All 
alcoholic  beverages  must  be  strictly  avoided.  Should 
the  urine  be  excessively  acid  or  alkaline,  the  free  use 
of  soda-water  or  lemonade  may  tend  to  correct  it. 

THERAPEUTICS    OF    URETHRITIS. 

I  Aconite.  Retention  or  suppression  of  urine,  from  cold., 
especially  in  children,  with  crying  and  restlessness.  Painful, 
anxious,  uj-ging  to  urinate.  (Borax.)  Mictuj-ition  painful, 
difficult,  drop  by  drop  ;  urine  scanty,  fiery,  scalding  hot,  red  or 
dark  colored.  (Apis,  ars.,  bell.,  cann.  ind.,  cannabis  sat., 
canth.,  capsicum,  nux  v.) 


64  DISEASES   OF   THE    URETHRA. 

Arsenicum.  Burning  in  the  urethra  during  micturition. 
(Aeon.,  can.  sat.,  canth.)  Involuntary  micturition.  (Arnica, 
bell.,  caust.,  cicuta,  liyosc,  opium,  puis.,  stramon.)  Urine 
scanty  ;  passed  with  difficulty  ;  burning  during  emission.  Sup- 
pression or  retention  of  urine.  (Aeon.,  camph.,  hyosc,  stra- 
monium, terebinthina.)  Hsematuria.  (Arnica,  canth.,  colch., 
ham.,  millcfoliufn,  petroleum,  phos.)      Albuminuria,  uraemia. 

Belladonna.  Atropine  is  preferred  by  some.  Retention 
of  urine,  which  passes  only  d7-op  by  drop.  (Aeon.,  canth.,  nux 
voin.)  Urine  becomes  turbid  (  C/z^/.),  with  reddish  sediment. 
(Carb.  veg.,  kreos.,  meg.,  sepia.)  Red,  sandy  sediment,  or 
like  brick-dust.  (Arnica,  cinch.,  coccus  cac,  lycop.,  nat.  mur., 
nux  vom.,  nuphar,  phos.)  Involuntary  micturition.  (Arnica, 
ars.,  caust.,  cicuta,  hyosc,  opium,  puis.,  stram.)  Atropine  6x 
is  one  of  the  best  remedies  for  the  acute  symptoms  of  gonor- 
rhoeal  urethritis  with  concomitant  heat  and  inflammation  in  the 
vagina.     Bell,  ix  is  a  rarely-failing  remedy  for  nervous  dysuria.' 

Camphor  ix.  This  remedy  is  highly  recommended  by 
Dr.  Hughes  for  acute  strangury  of  a  spasmodic  form.  The 
symptoms  are  urgent  and  very  painful.  It  is  also  beneficial  if 
the  symptoms  have  followed  the  application  of  a  cantharides 
blister.     This  remedy  usually  relieves  promptly  if  at  all. 

1 1  Cannabis  sativa,  compare  with  cannabis  indicus.  Burn- 
ing, smarting  in  the  urethra,  from  the  meatus  backward ;  pos- 
teriorly stitching  while  urinating.  The  urethra  feels  inflamed 
and  sensitive  to  pressure  along  its  whole  length  (Arg.  nit.). 
Burning  while  urinating,  but  especially  just  after  (August., 
ant.  tart.,  canth.,  conium,  equisetum)  stitches  and  tearing 
sensations  in  the  urethra. 

II  Cantharis.  Violent  pains  in  the  bladder,  with  frequent 
urging;  intolerable  tenesmus.  Tenesmus  of  the  bladder  {^Merc. 
r^T.,  capsic,  colch.).  Violent  burning,  cutting  pains  in  neck 
of  bladder.  Passage  of  blood  from  the  urethra,  or  bloody  urine 
{Ars.,  arnica,  colch.,  ham.,  mez.,  millefolium,  petroleum, 
phos?).  Violent  bu7'ning,  cutting  pains  in  the  urethra  before, 
during,  and  after   micturition   (Ant.  tart.,  can.  sat.,  conium, 

'   Hughes'  TheiapeLitics,  Part  11.,  p.  257. 


THERAPEUTICS.  65 

staphis.).  Urine  scalds  her,  passes  drop  by  drop  (Aeon., 
bell.).  Urging  to  urinate,  with  burning  sensation  in  urethra. 
This  is  a  veiy  effectual  remedy  for  inflammatory  dysuria,  but 
Dr.  Hughes  states  that  he  has  had  better  success  with  copaiba 
and  eupatorium  purpureum. 

Equisetum.  Bladder  feels  sore,  tender,  and  as  if  dis- 
tended, not  relieved  by  urination.  Constant  desire  to  urinate, 
and  much  burning  in  the  urethra  during  and  pain  after  the  flow 
of  urine  (Apis.,  canth.,  can.  sat.).  Urine  scanty  and  high 
colored  (Aeon.,  apis.). 

Eucalyptus  globulus."  Dr.  Woodbury  believed  he 
cured  several  cases  of  vascular  tumors  of  the  urethra  with  this 
remedy. 

Gelsemium.  If  this  remedy  should  prove  as  successful  in 
the  female  as  in  the  male,  to  abort  urethritis,  especially  gonor- 
rhoea, in  the  very  beginning  of  the  disease,  it  will  rank  as  one 
of  our  best  remedies.  It  must  be  given  low,  —  gi  or  ix.  dil.,  — 
to  obtain  prompt  effects. 

I  Merc.  cor.  Tenesmus  of  the  bladder  (^Canth.,  caps., 
eolch.)  ;  urine  suppressed'  (Aeon.,  hyos.,  stram.).  Frequent 
urination ;  passed  in  drops  with  much  pain  (Aeon.,  bell., 
canth.).  Urine  scanty,  bloody;  albuminous  (Osm.,  phos., 
phyt.,  plumb.),  containing  filaments,  flocks,  or  dark  flesh-like 
pieces  of  mucus.     Urethral  fever. 

Nux  vom.  Fai?iful,  ineffectual  urging  to  urinate  (Canth.)  ; 
urine  passes  in  drops  (Aeon.,  bell.,  canth.)  with  burning  and 
tearing  in  urethra  and  neck  of  bladder  (Apis.,  canth.,  can. 
sat.,  caps.) .  Urine  pale,  later  thick,  whitish,  purulent ;  reddish 
with  brick-dust  sediment.     Constipation  and  blind  hemorrhoids. 

II  Populus.  This  remedy  has  promptly  cured  when  canth., 
cannabis  sat.,  and  other  remedies  have  failed,  though  apparently 
well  indicated.  It  seems  to  act  best  in  a  low  preparation,  such 
as  populin  ix  trit.  Urination  is  painful,  with  hot  scalding  sen- 
sations, especially  during  pregnancy.  It  is  also  a  useful  remedy 
for  cystitis.  The  author  has  found  it  a  good  remedy  for  tenes- 
mus of  the  bladder  after  ovariotomy. 

1  Dr.  J.  H.  Woodbury:  New-England  Medical  Gazette,  June,  1S75. 


66.  DISEASES   OF  THE    URETHRA. 

Thuja.  Judging  from  its  action  on  various  excrescences,  it 
would  seem  to  be  applicable  to  those  of  the  urethra,  though  the 
provings  do  not  indicate  so  marked  an  action  on  this  region 
as  do  many  other  remedies. 

The  foUoiving  remedies  may  be  consulted  for  further  study  : 
ant.  tart.,  apis,  arnica,  benzoic  acid,  berberis,  calc.  carb., 
capsic,  causticum,  clematis,  coloc,  con.,  copaiba,  eupatorium 
purpureum,  ferrum,  hepar,  hyosc,  lil.  tig.,  lycop.,  nat.  mur., 
nit.  ac,  puis.,  sang.,  sarsp.,  sepia,  sulph.,  thlapsi  bursa  past. 


CYSTITIS.  67 


CHAPTER   IV. 

CYSTITIS. 

THE  pathology  and  etiology  of  cystitis,  or  inflamma- 
tion of  the  bladder,  in  the  female,  is  similar  to  the 
same  disease  in  the  male;  except  that  in  the  former  there 
are  the  additional  causes  of  displacement  of  the  uterus, 
either  irritating  or  preventing  the  complete  evacuation 
of  the  bladder  ;  the  prolonged  retention  of  urine  after 
parturition  ;  too  early  closure  of  a  vesico-vaginal  fistula ; 
and  the  habit  of  retaining  the  urine  an  undue  length  of 
time,  —  a  more  common  cause  in  women  than  in  men. 

As  the  disease  is  not  peculiar  to  the  female,  the 
reader  is  referred  to  the  standard  text-books  on  medi- 
cine and  surgery  for  more  detailed  descriptions  than 
will  be  here  given.  The  treatment  varies  a  little,  how- 
ever, as  the  organ  is  much  more  accessible. 

Symptoms.  —  In  the  acute  form,  frequent  micturition, 
only  a  few  drops  being  voided  at  a  time  with  much 
straining  or  tenesmus  afterward,  is  one  of  the  most 
prominent  symptoms.  The  bladder  often  seems  intol- 
erant of  even  a  very  small  amount  of  urine.  In  the 
chronic  form,  however,  the  organ  often  contains  a  large 
quantity,  which  frequently  becomes  ammoniacal.  In 
both  there  is  more  or  less  dull,  aching  pain  in  the 
region  of  the  bladder.  The  patient  may  be  unable  to 
completely  evacuate  the  viscus  in  chronic  cystitis,  so 
that  it  is  always  a  good  rule  to  introduce  the  catheter 


68 ,  CYSTITIS. 

in  suspected  cases.  Sometimes  a  quart  of  offensive  alka- 
line urine  will  be  withdrawn  in  this  way.  On  standing, 
the  urine  separates  into  a  clear  fluid  above,  with  a  vary- 
ing amount  of  mucus  or  pus  at  the  bottom  of  the  vessel. 
Under  the  microscope,  there  is  seen  epithelium,  pus, 
and  blood  corpuscles.  Membranous  exudations  are 
sometimes  present. 

Pyelitis  may  have  very  similar  symptoms  to  cystitis, 
but  the  differential  diagnosis  of  pyelitis  is  made  by  the 
lumbar  pain,  the  even  admixture  of  pus  with  the  urine, 
the  acid  reaction,  the  absence  of  ropy,  gelatinous  mucus, 
and  the  presence  of  "tailed"  cells,^  or  "epithelium 
from  the  pelvis  of  the  kidney,  distinguishable  by  the 
frequent  occurrence  in  a  cell,  of  clearly  defined,  dark- 
colored,  round  granules,  and  of  two  nuclei."^  Flint,^ 
however,  does  not  believe  the  character  of  the  epithelial 
cells  can  be  relied  on  to  differentiate  the  two  diseases. 

TJie  Prognosis  becomes  more  grave  in  proportion  to 
the  duration  of  the  disease.  The  acute  form  usually 
terminates  within  a  week  or  ten  days  ;  the  chronic 
may  last  for  years,  and  end  fatally  if  left  to  itself.  If 
the  disease  has  not  extended  to  the  kidneys,  a  cure 
may  be  expected  in  the  majority  of  cases. 

The  diet  should  be  the  same  as  in  the  preceding 
chapter  on  diseases  of  the  urethra.  The  free  use  of 
milk  is  of  great  importance.  Mineral  water  charged 
with  carbonic-acid  gas  is  also  useful.  Dr.  Ludlam 
warmly  recommends  clysmic  spring  water. 

Washing  out  the  bladder  is  an  indispensable  aid  to 
internal  remedies  in  the  treatment  of  chronic  cystitis. 
No  local  measures  whatever  are  necessary  in  the  acute 
form.     The  following  rules  should  be  observed  :  — 

'  Loomis,  Practical  Medicine. 
^  Da  Costa,  Medical  Diagnosis. 
i  Flint's  Practice  of  Medicine. 


IRRIGATION  OF  THE  BLADDER.  69 

1.  Use  a  fountain  syringe,  and  inject  slowly. 

2.  Proportion  the  quantity  of  tepid  fluid  to  the  toler- 
ance of  the  bladder. 

3.  The  irrigation  may  be  repeated  one  to  four  times 
a  day,  according  to  the  severity  of   the  case. 

4.  Use  either  the  double-current  catheter,  or  a  two- 
way  stop-cock.'  Dr.  Munde  states  that  pure  water 
should  not  be  used,  as  it  is  liable  to  irritate  the  blad- 
der. 

An  excellent  way  to  wash  out  the  bladder  is  to  use 
a  two-way  stop-cock,  or  the  T  just  referred  to. 


CODMAN   &,   SHURTLEFF, 

BOSTON.  0 

Fig.  39-    Instrument  for  Washing  out  the  Bladder. 

Introduce  a  large  gum  elastic  catheter,  somewhat 
shortened,  into  the  bladder,  the  larger  the  better  if  it 
does  not  cause  an  undue  amount  of  pain.  Connect  this 
with  the  long  arm  of  the  T  (A  B),  and  the  syringe 
with  the  upright  or  body  of  the  instrument  (D).  Attach 
a  piece  of  three-sixteenths-inch  rubber  tubing,  about 
eighteen  inches. long,  to  the  short  arm  of  the  T  (C). 
Now  let  the  water  run  slowly  in  from  the  syringe  ;  when 
it  escapes  from  the  rubber  tubing,  compress  the  latter 
between  the  thumb  and  finger ;  this  forces  the  water 
into  the  bladder.  As  soon  as  the  patient  feels  a  slight 
distension,  remove  the  pressure  from  the  rubber  tube, 
and  the  bladder  will  empty  itself.  This  may  be  re- 
peated till  the  water  returns  clean  from  the  bladder. 

'  Codman  &  Shurtleff  of  this  city  make  an  excellent  T-shaped  instrument  for 
this  purpose, 


70  •  CYSTITIS. 

Meantime  the  medicated  fluid  has  been  prepared,  and, 
as  soon  as  the  washing  is  finished,  is  poured  into  the 
syringe,  and  injected  in  the  same  way.  It  may  be 
retained  one  to  five  minutes,  and  then  allowed  to 
escape. 

Non-alcoholic  preparations  are  preferable.  They  may 
be  prepared  by  diluting  the  solid  extract  with  water  and 
glycerine,  or  evaporating  the  watery  extract  to  the  re- 
quired strength.  The  following  are  recommended, 
which  should  never  be  strong  enough  to  give  pain:  — 
Hydrastis,  i  :  lo  of  the  tincture,  or  the  muriate  of 
hydrastine  2  grs.  to  the  ounce  of  water,  if  the  urine  is 
loaded  with  mucus. 

Calendula,  1:10  of  the  tincture,  if  the  urine  is  bloody 
and  contains  a  quantity  of  pus. 

An  infusion  of  these  remedies  is  also  excellent. 
Common  salt  and  water,  one  drachm  to  the  pint,  has 
been  warmly  recommended  as  a  cleansing  fluid.  If 
there  is  much  suppuration,  a  one-per-cent  solution  of 
carbolic  acid,  or  one  in  five  thousand  of  corrosive  sub- 
limate, is  excellent.  When  the  urine  is  ammoniacal  and 
offensive,  either  the  solution  of  carbolic  acid,  or  half  a 
drachm  of  dilute  nitro-muriatic  acid  to  a  pint  of  water 
may  be  used ;  if  acid,  the  same  amount  of  saleratus 
instead  of  the  acid.  A  solution  of  quinine  has  also  met 
with  some  favor.' 

'  Mr.  Nunn  finds  a  solution  of  quinine  very  useful  for  injections  in  the  bladder, 
when  the  urine  is  loaded  with  pus  and  intensely  offensive,  the  bladder  being  irrita- 
ble with  a  frequent  desire  to  urinate.  He  uses  it  in  the  following  manner  :  Dissolve 
twenty  grains  of  the  disulphate  of  quinine  in  twenty-five  ounces  of  water,  by  the 
aid  of  a  few  drops  of  dilute  sulphuric  acid,  or  a  teaspoonful  of  common  brown  vin- 
egar. Of  this  solution,  inject  two  or  three  ounces,  and  let  it  remain.  —  Londoit 
Lancet,  Feb.  23,  1S78,  p.  270. 

Mr.  J.  Knowlsley  Thornton  reports  two  cases  of  irritation  of  the  bladder  after 
ovariotomy  treated  very  successfully  by  the  quinine  solution,  two  grains  to  the 
ounce,  dissolved  with  a  few  drops  of  dilute  sulphuric  acid.  Three  punces  were 
injected,  and  in  a  few  seconds  two  were  withdrawn,  leaving  one  ounce  in  the 
bladder.  —  London  Lancet,  June  i,  1878,  p.  7S6. 


THERAPEUTICS  OF  CYSTITIS.  71 

Sir  Benjamin  Brodie  found  pareira  brava  very  useful 
where  there  was  a  tendency  to  profuse  mucous  secre- 
tion. 

Sir  Henry  Thompson  recommends  a  strong  decoc- 
tion of  triticum  repens/  which  is  also  well  spoken  of  by 
Graily  Hewitt.^ 

I  have  had  no  experience  with  this  remedy,  but  refer 
to  it  because  it  comes  from  such  excellent  authority. 

If  there  is  no  improvement  after  a  sufficient  trial  of 
carefully  selected  remedies  with  proper  irrigation  of  the 
bladder,  the  production  of  an  artificial  vesico-vaginal 
fistula,  i.e.,  cystotomy,  affords  the  best  prospect  of  cure. 
It  may  be  done  with  the  thermo-cautery,^  but  incision 
is  preferable.4 

It  is  needless  to  say,  that  displacements  of  the  uterus 
should  be  corrected,  and  if  cystocele  be  present,  it  will 
almost  invariably  be  necessary  to  operate  on  it  in  such 
a  way  that  no  pouch  will  be  left  for  the  retention  and 
decomposition  of  the  urine. 

THERAPEUTICS    OF    CYSTITIS. 

Compare  the  remedies  mentioned  for  urethritis.  For  acute 
cystitis.  Aeon.,  apis,  belladonna,  cann.  sat.,  canth.,  eucalyptus 
globulus,  eupator.  purp.,  equisetiim  hyeniale,  mere,  cor.,  nux 
vom.,  populus,  puis.,  sepia,  sulph.,  sulpho-carbolate  of  soda, 
terebinthina. 

While  any  of  the  preceding  remedies  may  be  indicated,  the 
following  are  more  generally  useful  in  chronic  cystitis :  ammon. 
mur.,  benzoic  acid,  calc.  carb.,  chimaphilla,  copaiva,  cubebs, 
epigea  repens,  equisetum  hy.,  eucalyptus,  hydrastis,  lithia  carb., 
lycopod.,  pareira  brava,  phytolacca,  populus,  uva  ursi. 

'  Boil  four  ounces  of  triticum  repens  in  a  quart  of  water,  gently  reducing  it  to  a 
pint ;  strain  and  cool ;  let  a  third  part  be  taken  three  times  a  day.  Reynolds' 
System  of  Med.,  vol.  iii.  p.  476. 

^  Dis.  of  Women,  vol.  ii.  p.  481,  1883. 

3  Dr.  M.  A.  Patten  :  Am.  J.  of  Obst.,  vol.  xi.,  April,  1878. 

*  Emmet's  Principles  and  Practice  of  Gynaecology,  p.  7S0,  1884. 


72  CYSTITIS. 

I  Aconite.  Cystitis  from  metastasis  of  rheumatism  ;  acute 
cystitis  from  exposure  to  cold.  Painful,  anxious  urging  to 
urinate  (Borax).  Micturition  painful,  difficult,  drop  by  drop; 
urine  scanty,  fiery,  scalding  hot,  red  or  dark-colored.  (Apis, 
a7's.,  bell.,  cann.  ind.  and  sativa,  canth.,  capsic,  nux  vom., 
popuius.) 

Apis.  Cystitis  from  the  abuse  of  canth.,  camph.,  or  other 
drugs.  Burning  soreness  when  urinating.  Frequent  desire, 
with  passage  of  only  a  few  drops.  Urine  scanty  and  high 
colored,  or  suppressed  (Aeon.,  hyosc,  stram.)  ;  it  may  also  be 
frequent  and  profuse.     Burning  and  stinging  in  the  urethra. 

Belladonna.  Acute  cases  :  nervous  dehcate  women  who 
do  not  sleep,  and  are  inclined  to  greatly  exaggerate  their  sensa- 
tions. Vesical  region  very  sensitive  to  pressure  or  jar.  Reten- 
tion of  urine,  which  passes  drop  by  drop.  (Aeon.,  canth.,  nux 
vom.)  Urine  hot  and  fiery  red  ;  at  first  clear,  becomes  turbid 
on  standing  {Chel.,  turbid  on  passing),  with  reddish  sediment 
(Carb.  veg.,  kreos.,  mez.,  sepia),  red,  sandy  sediment,  or  like 
brick-dust  (Arnica,  cinch.,  coccus  cac,  lycopodium,  nat.  mur., 
nux  vomica,  nuphar,  phos.) .  Paralysis  sphincter  vesicae  ;  con- 
stant dribbling  of  urine.  If,  with  the  urinary  symptoms,  there  is 
acute  congestion  and  bearing-down  of  the  pelvic  organs,  which 
are  sensitive,  and  the  examining  finger  feels  distinct  pulsations 
of  the  blood-vessels,  belladonna  will  usually  relieve  promptly. 

Dr.  Ludlam  reccommends  atropine  3,  every  hour,  for  very 
acute  cases  of  gonorrhoeal  origin.' 

II  Cannabis  sat.  This  remedy  is  so  closely  related  to  can- 
tharides,  it  is  sometimes  difficult  to  decide  which  is  indicated. 
Its  action  is  less  intense  than  the  latter,  and  when  the  particu- 
lar remedy  is  not  clearly  indicated,  it  may  be  best  to  give 
cannabis,  if  cantharis  has  given  no  relief  in  twenty-four  hours. 
Dr.  F.  E.  Doughty  states  that  it  is  particularly  useful  in  gonor- 
rhoeal cystitis.  Strangury.  Drawing  pain  from  the  region  of 
the  kidneys  to  the  inguinal  glands,  with  anxious,  nauseous  sen- 
sation in  pit  of  stomach.  Burning,  smarting  in  the  urethra 
while  urinating,  and  especially  jitst  after. 

I  Dis.  of  Women,  p.  579.     18R1. 


THERAPEUTICS   OF  CYSTITIS.  73 

II  Cantharis.  The  chief  remedy  for  acute  cystitis.  Sup- 
pressed gonorrhoea  with  bloody  urine,  which  is  discharged  drop 
by  drop,  with  intense  burning.  Violent  pains  in  the  bladder, 
with  frequent  urging ;  intolerable  tenesmus.  {Merc,  cor.,  cap- 
sicum, colch.,  terebinthina.)  Violent  burning,  cutting  pains 
ill  the  neck  of  the  bladder.  Passage  of  blood  or  bloody  urine. 
{Ars.,  arnica,  colchicum,  ham.,  mez.,  niillefolium,  petroleum, 
phos.,  terebinthina.)  Violent  burning,  cutting  paitis  in  the 
urethra  before,  during,  and  after  micturition.  (Ant.  tart., 
can.  sat.,  conium,  staphis.)  Urine  scalds  her,  passes  drop  by 
drop.  Urging  to  urinate,  with  inability  or  difficult  emission  of  a 
few  drops.  Urine  turbid,  scanty,  albuminous,  contains  shreds 
and  mucus  ;  looks  jelly-like.  Great  thirst,  nausea,  and  vomiting. 
Abdomen  distended  and  painful,  especially  above  the  symphysis 
pubis,  with  burning  pains  in  the  loins.  Niemeyer  '  states  that 
in  croupous  cystitis,  which  sometimes  follows  the  abuse  of 
cantharides  or  difficult  forceps  deliveries,  we  occasionally  see 
large,  tenacious,  false  membranes  discharged  with  the  urine. 
This  hint  should  not  be  lost  sight  of  in  treating  diptheritic, 
croupous,  or  gangrenous  cystitis.  Baehr  thinks  cantharides  are 
scarcely  ever  appropriate  to  the  chronic  form,  and  has  frequently 
seen  instantaneous  aggravations  after  the  third  trituration. 

II  Chimaphila  umb.  g).  A  favorite  remedy  of  Dr.  Hughes 
for  chronic  cystitis.  Ulceration  of  the  bladder.  Scanty  uriiie, 
containing  a  large  quantity  of  ?nuco-p7irulent  sediment.  Urine 
thick,  ropy,  of  brick  color,  and  copious  bloody  sediment. 
Constipation. 

Colocynth.  Frequent  desire  to  urinate,  with  scanty  dis- 
charge. (Apis,  dig.,  graph.,  hell.,  mere,  nit.  ac.)  Urine  fetid, 
brown,  viscid,  deposits  copious,  jelly-like  sediment.  The  pains, 
while  urinating,  are  felt  over  the  whole  abdomen.  It  is  best 
adapted  to  the  acute  stage,  at  about  the  fifth  day,  when  the 
pains  diminish,  and  mucus  begins  to  appear  in  the  urine. 

Dulcamara.  Sub-acute  form  resulting  from  local  damp 
and  cold.  The  deposit  from  the  urine  looks  like  the  white  of 
t.gg  slightly  cooked. 

'  Niemeyer,  Practical  Medicine,  vol.  ii.  p.  70.     1879. 


74  CYSTITIS. 

I  Equisetum  hy.  Dysu?-ia,  extreme  and  frequent  urging  to 
urinate,  witli  severe  pain,  especially y^jY  after  voiding  the  urine. 
Dysuria  after  confinement  and  during  pregnancy.  Pain  and 
tenderness  in  region  of  bladder,  with  feeling  of  distention .  Urine 
high-colored  and  scanty. 

Eucalyptus  glob.  Dr.  F.  E.  Doughty '  has  found  this 
remedy  very  useful  for  sub-acute  cases,  in  doses  of  three  to  five 
drops  of  the  oil. 

Merc.  cor.  Tenesmus  of  the  bladder.  {Canlh.,  capsic, 
colch.)  Urine  suppressed.  (Aconite,  hyos.,  strani^  Frequent 
\xx\Vi^\S.oxv,  passed  in  drops  with  much  pain.  (Aeon.,  bell.,  canth^ 
Urine  scanty,  albuminous  (Osm.,  phos.,  phyt.,  plumb.'),  con- 
taining filaments,  flocks,  or  dark  flesh-like  pieces  of  mucus. 

Nux  vomica.  Tenesmus ;  burning  and  pressure  in  the 
bladder.  (Ars.,  canth.,  aeon.)  Painful,  itieffectual  urging 
to  urinate  ;  uri?te  passes  in  drops,  with  burning  and  teari?tg  in 
the  urethra  and  neck  of  the  bladder.  Urine  at  first  pale  ;  but 
later,  thick,  with  reddish  or  muco-purulent  sediment. 

I  Pareira  brava.  Dysuria.  Constant  urging  to  urinate. 
Urine  contains  much  thick,  viscid,  white  mucus,  or  deposits  a 
red  sand,  and  has  a  strong  ammoniacal  odor. 

Phosphorus.  Hcematuria.  (Ars.,  canth,,  colch.,  hamamehs, 
millefoliujn,  petroleum.)  Urine  turbid,  whitish,  with  brick-dust 
sediment,  and  variegated  cuticle  on  the  surface.  Paralysis  of  the 
bladder.    (Hyosc,  caust.,  carbo  vegetahs,  plumbum,  sulphur.) 

I  Terebinthina  IX.  Acute  cystitis.  Violent  burning,  draw- 
ing pains  in  region  of  kidneys.  Urine  scanty  and  bloody,  may 
be  suppressed.     The  relief  is  usually  prompt. 

The  following  remedies  may  be  consulted  in  addition  to  the 
preceding :  — 

Ammonia  mur.,^  ars.,  benzoic  acid,  carbo  vegetalis,  caust., 
cocculus,  copaiva,  cubebs,  digitalis,  elaterium,  epigea  repens, 
eupator  purp.,  graph.,  hydrastis,  hyosc,  kali  carb.,  lithia  carb., 
lye,  phos.  ac,  Phytolacca,  plumbum,  populus,  puis.,  sepia, 
squills,  sulphur,  sulpho-carbolate  of  soda,  uva  ursi. 

•  Arndt's  System  of  Medicine,  vol.  ii.  p.  216. 

^  This  was  a  favorite  remedy  of  Dr.  J.  F.  Gray  for  chronic  cystitis. 


PRURITUS   VULV^.  75 


CHAPTER    V. 
PRURITUS  VULVAE. 

THIS,  as  the  name  signifies,  is  an  itching  of  the  vulva, 
a  symptom,  but  not  a  disease.  It  is  not  always 
limited  to  the  external  genitals,  and  is  liable  to  extend 
over  the  adjoining  surface  in  pregnancy,  at  the  climac- 
teric, and  if  it  depends  on  eczema  of  the  vulva.  It  runs 
no  definite  course,  and  may  last  for  years,  causing  much 
suffering  and  misery  to  the  patient.  The  causes  are 
numerous,  but  the  more  important  ones  can  be  classified 
briefly  as  follows  :  — 

LOCAL. 

Irritating  Discharges.  —  Leucorrhcea,  acrid  discharge'  from 
cancer  of  cervix,  dribbling  of  urine. 

Skin  Diseases.  —  Eczema  of  vulva,  inflammation  of  the  vulvar 
mucous  membrane  with  or  without  aphthae,  trichiasis. 

Parasites.  —  PedicuH  pubis,  acari,  ascarides,  fungoid  organ- 
isms.2 

GENERAL. 

Congestion  of  the  pelvic  organs,  pregnancy,  diabetes.'i  In  some 
cases  it  appears  to  be  a  kind  of  neurosis,  or  hypereesthesia  of  the 
nerves. 

'  McClintock  states  that  this  is  one  of  the  earliest  symptoms  of  cancer.  I  am 
not  aware  that  this  has  been  confirmed  by  other  observers. 

^  Some  think  pruritus  depends  almost  entirely  on  these  growths,  as  the  most 
effectual  applications  are  also  parasiticides.  For  further  information  see  Friedrich 
Virchow's  Archiv.  vol.  30,  p.  476;  and  Wiltshire,  Brit.  Med.  Journal,  March  5, 
18S1. 

3  It  is  the  condition  of  the  urine,  rather  than  the  influence  of  the  disease  on  the 
organism,  which  produces  pruritus. 


76    ,  PRURITUS   VULV^. 

Although  the  surface  may  be  scratched,  and  show 
much  local  irritation,  it  is  always  a  good  rule  to  test  the 
urine  for  sugar. 

The  food  should  be  plain  and  nutritious.  Any  form 
of  alcoholic  drink,  coffee,  or  an  abuse  of  pepper  or  con- 
diments, is  liable  to  aggravate  the  trouble.  The  wife 
should  occupy  a  separate  room.  Feather-beds  and  too 
warm  clothing  tend  to  cause  congestion  and  increase 
the  irritation. 

The  same  general  rules  for  treating  similar  conditions 
on  other  portions  of  the  body  also  apply  here.  As  the 
great  majority  of  cases  depend  on  the  presence  of  some 
irritating  discharge,  cleanliness  is  of  prime  importance. 
Frequent  ablutions,  two  or  three  times  a  day,  with  cas- 
tile  or  the  honey  and  juniper  tar  soaps  are  indispensable. 
Direct  the  patient  to  dry  the  parts  carefully  with  a  linen 
cloth  after  her  bath,  to  insert  a  tampon  of  dry  absorbent 
cotton  in  the  vagina,  and  apply  calendula  cerate  in  which 
enough  muriate  of  cocaine  has  been  mixed  to  make  a 
four  per  cent  oleate.  The  vaginal  tampon  is  of  great 
importance  if  there  is  an  acrid  discharge. 

The  cure  will  be  much  more  satisfactory  if  made  with 
pure  water  douches  and  the  accurate  prescription  of  the 
single  remedy.  As  a  rule,  however,  patients  will  not 
wait,  and  demand  something  to  relieve  promptly  their 
present  suffering.  There  is  no  one  cure-all,  as  the  many 
different  applications  testify.  The  following  are  recom- 
mended by  good  authorities,  from  which  a  selection  can 
be  made  if  the  former  measures  are  insufficient.  It  is 
hardly  necessary  to  mention,  that  short  bristly  hairs 
projecting  into  the  mucous  surface  should  be  removed 
with  tweezers  by  the  aid  of  a  magnifying-glass.  A 
pledget  of  lint  or  old  linen  rolled  in  almond-oil  may  be 
placed  between  the  labia  or  in  the  vagina,  if  that  be  the 
site  of   the  pruritus.     If  there  is  a  vesicular  eruption 


LOCAL    TREATMENT  OF  PRURITUS    VULVAi.     77 

with  a  raw  surface  on  the  mucous  membrane,  or  very 
marked  burning  in  the  urethra,  and  dysuria,  medicate 
the  almond-oil  with  tincture  of  cantharis,  and  apply 
in  the  same  way.  In  case  the  inflammation  is  of  the 
erythematous  form,  with  a  scarlet  surface  and  nettle- 
like  stinging  and  burning,  substitute  urtica  urens  for 
the  cantharis.' 

Eczema  of  the  vulva  is  sometimes  an  obstinate  affec- 
tion. Here,  water  is  liable  to  aggravate,  and  success 
depends  almost  entirely  on  the  internal  remedy.  Judg- 
ing from  favorable  reports  of  a  one  per  cent  cerate  of 
chrysophanic  acid  in  eczema  on  the  body  elsewhere,  it 
might  be  used  with  advantage  here.^  Dr.  A.  Martin  has 
found  iodoform  ointment  beneficial. ^ 

In  aphthous  inflammation  of  the  vulva,  a  solution  of 
borax  and  water  (five  to  ten  grains  to  the  ounce,  or  a  tea- 
spoonful  of  boracic  acid  dissolved  in  a  pint  of  boiling 
water)  was  highly  recommended  by  Sir  James  Simpson 
and  also  by  Hering.^  A  lotion  of  hydrastis  is  also  use- 
ful in  these  cases. 

Painting  the  surface  with  a  solution  of  nitrate  of 
silver  is  favorably  mentioned  by  good  authority,  if  the 
pruritus  depends  upon  a  virulent  catarrhal  inflamma- 
tion, and  for  very  obstinate  chronic  cases,  especially  if 
syphilitic. 

The  prognosis  is  grave  when  diabetes  is  the  cause  of 
the  pruritus.  The  use  of  the  catheter,  thorough  bathing 
after  each  micturition,  and  the  liberah  use  of  vaseline 
to  protect  the  parts,  will  afford  much  relief.  Schroeder 
states  that  the  Carlsbad  water  affords  the  best  prospect 
for  a  cure.  5 

'  Ludlam,  Diseases  of  Women,  p.  532. 

=  Dr.  Utley:   New-England  Medical  Gazette,  July,  1SS4. 

3  Centralblatt  fiir  Gynakologie,  July  3,  iSSo. 

*  Domestic  Physician,  p.  274. 

5  Schroeder,  Krank.  der  weibl.  Organen,  p.  528. 


78  PRURITUS    VULV^. 

In  some  cases  where  there  is  much  local  inflamma- 
tion, poultices  of  linseed,  slippery  elm,  potato,  etc.,  will 
relieve ;  though,  as  a  rule,  heat  is  likely  to  aggravate. 

Hewitt '  finds  one  part  of  chloroform  mixed  with  six 
of  almond-oil  very  useful.  This  is  somewhat  stronger 
than  the  mixture  recommended  by  Scanzoni  (i  :  lo), 
who  speaks  well  also  of  caladium  seguinum  locally.  In 
prurigo  senilis,  pruritus  in  the  aged,  a  cerate  of  the  oil 
of  staphisagria  seeds  (one  part  of  the  oil  to  seven  of 
vaseline)  is  very  beneficial. 

Schroeder^  prefers  a  three  to  ten  per  cent  solution 
of  carbolic  acid,  applied  with  a  camel's-hair  pencil  after 
an  alkaline  sitz-bath.  In  some  chronic  cases  there  are 
found  on  the  labia  one  or  more  tubercles  or  very  sensi- 
tive spots  which  are  the  sites  of  the  pruritus  :  removal 
of  these  by  scalpel  or  scissors  has  been  followed  by  a 
permanent  cure.^  When  the  pruritus  seems  to  consti- 
tute a  neurosis,  relief  may  be  given  by  electricity,  pref- 
erably the  Faradic  current. 

Emmet  4  uses  one-half  ounce  of  sulphurous  acid,  mixed 
with  half  a  pint  of  warm  water,  for  the  aphthous  variety, 
and  states  that  in  old  people  benefit  will  be  derived  from 
arsenic  internally  and  iodoform  locally.  Tar  5  in  alco- 
holic solution  (4  :  30),  or  with  glycerine,  is  praised  by 
Martin  and  Weston.  Plantago  cerate  has  cured  some 
cases. 

Parasites  are  sometimes  the  cause  of  the  pruritus. 
The  most  common  of  these  is  the  pediculus  pubis,  or 
crab  louse.     It  is  so  small  as  to  readily  escape  notice ; 

'  Hewitt,  Dis.  of  Women,  vol.  ii.  p.  42S. 

2  Ibid. 

3  Schroeder,  Die  operative  Behandhingbei  Pruritus  Vulvae.  Sitzung  d.  geburts. 
Gesellschaft  z.  Berlin,  Nov.  11,  18S4;  and  Kiistner,  Centralblatt  fiir  Gynakologie, 
Nov.  II,  18S5. 

^  Principles  and  Practice  of  Gynaecology,  p.  631. 
s  Boston  Gyn.  Journal,  vol.  iv.  p.  79. 


PARASITES  OF  THE    VULVA.  79 

but  the  presence  of  nits  in  the  hair  and  severe  itching 
localized  in  one  place,  especially  about  the  pubis,  point 
to  them  as  the  cause.  They  are  easily  destroyed  by  the 
application  of  one  of  the  following  lotions  :  a  five-per- 
cent solution  of  carbolic  acid  ;  a  solution  of  corrosive 
sublimate,  half  a  grain  to  an  ounce  of  water  ;  and  the 
tincture  of  staphisagria. 

In  young  girls,  ascarides  sometimes  find  their  way 
into  the  vagina,  and  cause  much  irritation.  Thorough 
inunction  of  the  parts  with  an  ointment  made  of  one 
part  impure  carbolic  acid  well  rubbed  up  with  ten  of 
cold  cream  or  vaseline  will  destroy  both  the  acari  and 
their  ova.  Dr.  Holcombe  states  '  that  such  cases  are 
cured  by  nightly  injections  of  a  strong  decoction  of 
garlic,  with  an  internal  dose  of  ignatia. 

It  may  seem  that  an  unnecessarily  large  number  of 
local  applications  have  been  given  ;  but  in  many  cases 
any  one  loses  its  efficacy  after  a  while,  and  another  must 
be  tried ;  what  is  very  useful  in  one  case  is  often  worth- 
less in  the  next,  and  the  physician  must  have  a  number 
from  which  a  selection  can  be  made.  The  importance 
of  a  carefully  selected  remedy  to  cure  the  patient  can- 
not be  over-estimated. 

THERAPEUTICS. 

I  Ambra.  Violent  itching  of  the  vulva  (Canth.,  conium, 
kreos.,  mere,  sulph.)  during  pregnancy,  with  soreness,  itching, 
and  swelling  of  the  parts,  more  especially  during  pregnancy. 
Discharge  of  blood  between  the  peidods  from  slight  causes,  as 
after  a  hard  stool  or  walking.  Menses  too  early  and  too  pro- 
fuse. (Aloe,  ammon.  carb.,  ars.,  calc.  carb.,  carb.  veg.,  bell., 
coccus  cacti,  nux  vo7n.)  Emission  of  turbid  urine  depositing  a 
brownish  sediment.  Uterine  symptoms  are  worse  on  lying 
down. 

'  U.  S.  Med.  and  Surg.  Journal,  vol.  viii.  p.  49. 


8o  PRURITUS    VULV^. 

II  Caladium  Seguinum.'  According  to  Raue  and  Baehr, 
this  is  the  most  efificient  remedy.  Pruritus  vulvce,  cramp 
pains  in  tJie  uterus  after  midnight?-  Pruritus  during  preg- 
nancy.    Itching  pimples  on  the  genitals. 

Cantharis.  Climacteric  age.  Swelling  and  irritation  of  the 
vulva.  Violent  itching  in  the  vagina.  (Conium,  kreosotura, 
lil.  tig.,  mez.,  mere.)  Pruritus  with  strong  sexual  desire.  Dys- 
uria,  frequent  micturition  with  burning  and  cutting  pain. 
(Aeon.,  bell.,  can.  sat.,  mere,  cor.,  mix  votn.) 

I  Carbo  Veg.  Red,  sore  places  on  the  vulva ;  aphthae 
(Helonias),  itching,  sore  and  raw  during  leucorrhoea  (Merc). 
Leucorrhoea,  thin  in  morning  on  rising,  not  through  the  day ; 
milky,  excoriating  (compare  ars.,  conium,  kali  carb.,  kreosote). 
Menses  too  early  and  too  profuse  (Aloe,  ammon.  carb.,  ars., 
calc.  carb.,  carb.  veg.,  coccus  cac,  belt.,  mix  vom.)  ;  blood 
too  thick,  and  of  a  strong  odor.  Varices  of  the  vulva.  Carbo 
veg.  is  particularly  adapted  to  pruritus  associated  with  aphthae. 

Collinsonia  ix.  Distressing  itching  in  connection  with 
prolapsus  and  constipation.     Pruritus  during  pregnancy. 

Conium.  Severe  itching  deep  in  the  vagina.  (Canth., 
kreosotum,  lil.  tig.,  mez.,  mere.)  Leucorrhoea,  with  weak- 
ness and  paralyzed  sensation  in  small  of  back  before  the  dis- 
charge ;  thick,  milky,  with  contractive  labor-like  pain  coming 
from  both  sides,  of  white,  acrid  mucus,  causing  burning. 
{Alum,  iodine,  kreos.,  me?-c.,  phos.,  puis.)     Violent  itching  in 

'  British  Journal  of  Homoeopathy,  XIII.,  509;  XXVII.,  592;  XXIX.,  400, 
1871.     Compare  cases  i,  2,  and  3. 

(1)  Caladnun  ^.  A  girl  four  years  old  :  violent  itching  on  the  external  genitals. 
Six  drops  of  the  tincture  in  three  ounces  of  water,  a  teaspoonful  every  three  hours, 
cured. —  Dr.  Scholtz,  Zeit.f.  klin.  Med.,  vol.  v.  No.  i. 

(2)  Caladium  4>.  A  girl  twenty  years  old ;  frequently  returning  itching'  on  the 
genitals,  finally  with  voluptuousness  ;  three  months  later,  a  mucous  discharge  and 
very  troublesome  eruption  of  pimples  appeared  on  the  genitals.  Calad.,  eight  drops 
of  the  tincture  in  six  ounces  of  water,  a  tablespoonful  every  three  hours,  cured  her. 
—  Hid. 

(3)  Caladium   2x.     Mrs.    ,   age  45.     The  external  labia  were  swollen. 

There  was  a  papular  eruption  with  itching.     Calad.  2x  cured.  —  Dr.  J.  H.  Smith, 
British  Jourrial  of  Homceopathy,  p.  400,  1S71. 

^  See  proving  in  Transactions  American  Institute  of  Homoeopathy,  1881, 
p.  178. 


THERAPEUTICS   OF  PRURITUS    VULVAL.         8 1 

the  vulva  and  vagina,  especially  after  the  menses.  It  can  be 
also  used  locally  as  a  wash. 

Graphites.  Itching  of  the  pudenda  {Catad.,  angustura) 
before  menstruation.  Menses  too  late,  too  scanty,  and  too 
pale.  Vesicles  or  excoriations  in  the  vagina,  on  the  perineum, 
vulva,  and  between  the  thighs.  Aversion  to  coitus.  The  skin 
and  general  symptoms  are  important  aids  in  selecting  this 
remedy. 

II  Kreosotum.  Violent  itching  of  the  labia,  also  of  the 
vagina  (Canth.,  conium,  lil.  tig.,  mere,  mez.),  external  geni- 
tals swollen,  hot,  hard,  and  sore ;  soreness  and  smarting  be- 
tween the  labia  and  the  vulva.  (Sep.)  Itching  during  and 
after  menstruation.  Leucorrhcea  of  a  yellow  color,  staining 
linen  yellow,  with  great  weakness.      (Carb.  an.) 

Mercurius.  Leucorrhcea,  always  worse  at  night,  greenish 
discharge;  smarting,  corroding,  itching,  burning  after  scratch- 
ing. (Alum.,  coni.,  phos.,////?.)  Inflammation  of  vagina,  and 
especially  the  external  genitals,  with  rawness,  smarting,  and 
excoriated  spots.  (Carbo  veg.,  graph.)  Itching  of  the  geni- 
tals, worse  from  the  contact  of  the  urine. 

Rhus.''  In  eczema  of  the  vulva,  vesicular  or  pustular  erup- 
tions with  burning  and  itching. 

Sulphur.^     Burning  in  the  vagina.     Troublesome   itching 

^  (4.)  Rims  tox.  lox.  Patient  past  the  climacteric  ;  vulva  red,  swollen,  zV/z'^^^j^ 
itching,  often  worse  at  night  while  undressing,  aggravated  by  scratching,  and  fol- 
lowed by  soreness  and  smarting.  Mezereum,  which  had  relieved  a  similar  condition, 
failed.  Rhus  tox.,  lox  dil.,  cured.  —  Dr.  C.  Wesselhoeft,  New-England 
Medical  Gazette,  March,  1875. 

2  {<,.)  Sulphur  200.    Mrs. ,age47.    Violent  burning,  stinging,  and  scalding. 

Labia  swollen  to  twice  the  natural  size,  and  fiery  red ;  redness  extending  up  on 
the  abdomen,  down  on  the  inside  of  the  thighs,  and  around  the  anus.  Intense 
inflammation  inside  the  vulva,  and  the  surface  thickly  studded  with  miliary  points. 
The  pruritus  is  aggravated  by  the  heat  of  the  bed,  and  patient  suffers  intensely  after 
urination.     Specific  gravity  of  urine  1030,  and  an  abundance  of  sugar. 

Sulph.  6x.  prescribed  without  improvement  of  the  pruritus.  Six  days  later 
sulph.  200  was  given  with  marked  improvement.  In  two  weeks  examination  of 
urine  showed  sp.  grav.  1021,  sugar  19.68  grains  to  the  3.  The  same  remedy  was 
continued  with  steady  improvement.  In  another  fortnight  examination  of  the  urine 
showed  sp.  grav.  1014  with  only  a  trace  of  sugar.  In  a  few  days  more,  the  patient 
felt  perfectly  well,  and  was  pronounced  cured  six  months  after  the  commencement 
of  the  pruritus.  —  Dr.  Mary  Brownson,  Hahn.  Monthly,  p.  216,  1880, 


82   ■  PRURITUS    VULV^. 

of  the  genitals  with  papular  eruption  around  them.  (Merc.) 
With  this  remedy,  the  general  symptoms  indicating  it  are  ot 
more  importance  than  the  local. 

Other  Remedies  to  be  co7isulted.  —  Ars.,  calc.  carb.,  causticum, 
coffee,'  croton  tig.,  ferrum,  helonias,  hydrastis,  hydrocotyle 
Asiatica,-  kali  carb.,  lapis  albus -^  (silico-fluoride  of  calcium), 
HI.  tig.,  lycopod.,  mezereum,  nat.  mur.,  nit.  ac,  nux  vom., 
petroleum,  platina,  puis.,  sepia,  silicea,  staphisagria,  sulphate  of 
Bebeeria.'* 

'  Dr.  Brown-Seqiiard  has  observed  cases  of  pruritus  directly  caused  by  drinking 
coffee.  —  Medical  and  Surgical  Reporter,  June  5,  1886. 

^  Cured  very  severe  itching  of  the  vagina  in  12c.  dil.  See  British  Journal  of 
Homoeopathy,  vol.  16,  p.  589,  1858. 

3  (6.)  In  a  private  letter  to  the  author,  Dr.  Whiting  of  Danvers,  Mass.,  says  that 
he  has  used  this  remedy,  always  in  the  200  potency,  with  generally  good  results. 
He  was  led  to  it  by  observing  the  appearance  of  severe  pruritus  pudendi  in  a 
patient  whom  he  was  treating  successfully  for  bronchocele  with  lapis  albus  (silico- 
fluoride  of  calcium)  6x.  trit.  Omitting  the  lapis  albus,  he  gave  her  a  placebo,  and 
the  pruritus  entirely  disappeared.  She  again  received  lapis  albus  200,  a  dose  at 
bedtime,  and  in  a  very  few  days  the  pruritus  returned  with  such  intensity  that  she 
would  not  take  any  more  medicine.  It  also  cured  her  of  dysmenorrhoea  from 
which  she  had  suffered  for  over  twenty  years. 

'^  Recommended  in  five-grain  doses  in  British  Journal  of  Homoeopathy,  p.  168, 
1857. 


LACERATION  OF   THE   PERINEUM.  83 


CHAPTER  VI.    , 
LACERATION    OF    THE    PERINEUM. 

THE  diagnosis  of  this  lesion  is  easy,  whether  the 
sphincter  ani  be  involved  or  not.  An  excellent 
way  to  estimate  the  amount  of  injury  is  to  place  the 
thumb  against  the  anterior  margin  of  the  anus,  and 
the  tip  of  the  finger  just  within  the  vagina  ;  then 
bring  the  two  together,  and  the  thickness  of  the  peri- 
neal body,  if  any,  is  at  once  ascertained.  Visual 
inspection  alone  is  deceptive,  as  there  may  be  serious 
laceration  of  the  perineum  and  yet  the  outside  skin  re- 
main intact. 

The  treatment  of  this  lesion  is  surgical,  and  should 
not  be  deferred  till  cystocele  and  displacement  of  the 
uterus  have  taken  place.  A  reliable  rule,  from  a  clinical 
standpoint,  in  deciding  upon  the  necessity  for  an  opera- 
tion, is  to  ask  the  patient  if  she  is  troubled  at  all  by  an 
escapement  of  air  from  the  "front  passage."  If  so,  the 
operation  should  be  performed,  as  there  is  not  enough 
perineal  tissue  to  prevent  gaping  of  the  vaginal  orifice, 
or  to  support  the  uterus  ;  and  displacement  will  almost 
always  follow  in  time,  if  it  is  not  already  present. 

The  amount  of  support  given  to  the  uterus  by  the 
normal  perineum  is  a  mooted  question  ;  some  denying 
its  influence  altogether,  others  considering  it  all-impor- 
tant and  the  main  support  of  that  organ.  Space  can- 
not  be  given  to  the   discussion  of   this   matter.     The 


84  LACERATION  OF  THE   PERINEUM. 

truth  must  lie  between  these  extremes.  The  clinical 
fact  is,  that  with  few  exceptions  severe  laceration  of  the 
perineum  is  followed  by  rolling-out  of  the  vaginal  walls, 
and,  in  turn,  descent  of  the  uterus.  A  closer  examina- 
tion shows  that  the  vaginal  walls  seem  to  be  more 
relaxed,  and  do  not  have  the  same  elasticity,  and  firm 
attachment  to  the  underlying  structures,  as  in  virgins ; 
nor  is  this  always  due  to  sub-involution.  In  the  excep- 
tional cases,  which  nearly  every  practitioner  of  three  or 
four  years'  experience  has  seen,  there  may  be  severe 
laceration  of  the  perineum  without  uterine  displace- 
ment ;  but  here  the  vaginal  walls  are  not  so  flabby,  and 
do  not  roll  down  to  such  an  extent,  as  in  the  more 
common  cases.  How  are  these  differences  to  be 
reconciled  .'' 

While  the  author  regrets  he  has  not  yet.  had  an 
opportunity  of  verifying  the  following  explanation  by 
dissections,  he  ventures  to  give  it  as  based  on  clinical 
observation  of  such  cases.  In  the  former  case  of 
laceration  of  the  perineum  with  prolapsus  of  the  uterus, 
the  fascial  attachments  of  that  organ  to  the  surround- 
ing tissues  and  ligaments  at  its  insertion  into  the 
vagina,  as  well  as  the  fascial  and  muscular  fibres  in 
and  about  the  latter,  have  been  torn  or  so  injured  dur- 
ing labor,  that  when  the  prop  or  support  of  the  perineal 
fascia  or  body  is  gone  (for  laceration  of  the  so-called 
body  must  include  its  fascia),  the  structures  above  sag 
in  consequence,  and  yield  more  readily  to  intra-abdom- 
inal pressure.  As  lesions  of  the  perineum  vary  in 
extent,  so  may  the  injuries  to  the  fascia  of  the  genital 
tract.  If  that  of  the  perineum  alone  is  affected,  the 
fascia  and  muscular  fibres  above  it  may  be  quite  suffi- 
cient to  keep  the  uterus  and  vagina  in  place. 

Can  we  not  find  an  illustration  of  these  conditions  in 
the  treatment  of  procidentia  uteri .''     It  is  well  known, 


THE  PRIMARY  OPERATION.  85 

that  no  matter  how  carefully  the  perineum  be  repaired, 
and  the  caliber  of  the  vaginal  outlet  diminished,  after  a 
little  time  the  uterus  will  again  come,  down,  nor  does 
the  simple  narrowing  of  the  vagina  in  order  to  bring 
the  walls  into  close  contact  increase  to  any  extent  the 
immunity  from  a  recurrence  of  the  procidentia.  //  is 
not  till  the  vaginal  tissues  are  folded  in  and  so  drawn 
together,  at  the  cervix  titeri  especially,  as  to  take  up  the 
slack  of  the  muscular  fibres  and  fascia,  and  obtain  a 
new  hold  on  the  latter,  that  any  permanent  results  are 
obtained. 

While  the  perineum  is  an  important  factor  in  the 
support  of  the  pelvic  organs  above,  I  believe  that  the 
value  of  the  pelvic  fascia  in  sustaining  them  has  been 
overlooked. 

The  question  of  the  primary  operation,  i.e.,  imme- 
diate repair  of  the  injury  at  the  close  of  labor,  belongs 
to  the  province  of  obstetrics.  The  writer  cannot  for- 
bear, however,  from  expressing  his  opinion  that  all 
lacerations  more  than  one-fourth  inch  in  depth  beyond 
the  fourchette  should  be  closed  at  once,  taking  special 
care  that  the  whole  of  the  torn  surfaces  are  brought 
together  by  sutures.  I  have  had  every  opportunity  of 
observing  a  large  number  of  these  cases  in  hospital 
practice,  and  never  have  seen  as  good  union  take  place 
without  sutures,  as  can  be  obtained  with  them.  The 
apparent  extent  of  a  laceration  of  the  perineum  after 
delivery  is  very  deceptive.  The  tissues  are  bruised  and 
swollen,  and  in  forty-eight  hours  what  seemed  to  be 
an  extensive  laceration  will  oftentimes  appear  like  a 
moderate-sized  fissure  after  the  swelling  has  subsided. 
This  heals  by  granulation,  and  not  infrequently  a  cicatrix 
is  formed. 

Should  the  operation  not  be  performed  at  the  close  of 
labor,  it  is  better  to  wait  till  involution  is  completed,  and 


86.  LACERATION  OF   THE   PERINEUM. 

operate  four  or  six  months  after  the  confinement.  At 
this  time  the  scar  is  still  fresh,  and  forms  an  excellent 
guide  for  denudation  ;  the  tissues  are  also  vascular,  and 
unite  readily. 

The  forms  of  laceration  of  the  perineum  vary  much, 
as  every  physician  can  testify  who  makes  a  careful 
examination  of  each  case  after  labor.  They  very  sel- 
dom take  place  exactly  in  the  median  line,  but  usually 
extend  to  one  side  in  an  irregular  direction.  Some- 
times the  perineum  is  lifted  up,  or  dissected  off  the 
entire  anterior  surface  of  the  rectum,  by  the  advan- 
cing head,  and  then  splits  in  the  centre  so  as  to  form  a 
Y-shaped  laceration,  the  two  arms  of  the  Y  represent- 
ing the  surfaces  torn  off  the  rectum,  and  the  upright 
portion  the  central  split  in  the  perineum.  More  often, 
only  one  side  is  torn,  as  in  this  figure  {.  In  rare  in- 
stances the  perineum  is  torn  inside  while  the  external 
skin  is  intact.  Occasionally  there  is  complete  lacera- 
tion of  the  perineum,  involving  the  sphincter  ani  and 
rectum.  There  are  also  two  other  conditions,  which 
have  been  described,  but  are  very  rarely  seen  :  separa- 
tion of  the  tendons  in  the  perineum  without  lacer- 
ation of  the  mucous  membrane  or  skin  ;  and  central 
perforation  of  the  perineum,  in  which  the  child  was 
born  through  it  without  complete  laceration  of  that 
body. 

The  immediate  operation  of  perineorrhaphy  belongs 
to  obstetrics  rather  than  gynaecology,  and  will  not  be 
discussed  here  ;  nor  the  secondary  operation  for  com- 
plete laceration  through  the  sphincter  ani,  which  the 
general  practitioner  is  not  likely  to  undertake.  In 
these  cases  a  combination  of  the  methods  recom- 
mended by   Hegar  and  Kaltenbach  '  and   Emmet,^    is 

'  Hegar  und  Kaltenbach  :  Operative  Gynakologie,  p.  741.     1881. 
^  Emmet  :  Principles  and  Practice  of  Gynaecology,  p.  392.     1884. 


PERINEORRHAPHY   WITHOUT  A    RECTOCELE.     87 

advisable.  The  reader  is  also  referred  to  these  authori- 
ties for  peculiar  modifications  of  this  operation  required 
by  various  severe  lesions  of  an  unusual  form.' 

Secondary  or  deferred  perineorrhaphy,  for  incomplete 
laceration  of  the  perineum,  is  one  of  the  most  common 
of  the  gynaecological  operations,  and  v^ill  therefore  be 
described  in  some  detail  according  to  those  methods 
which  the  author  believes  from  his  experience  and 
observation  are  best  calculated  to  most  efficiently 
repair  the  lesion. 

Clinically  these  lacerations  are  divided  into  two 
classes, — those  without  and  those  with  rectocele,  each 
having  an  operation  adapted  to  it.  It  is  to  be  re- 
membered, that  these  operations  are  also  applicable  to 
relaxation  or  atrophy  of  the  perineum  from  any  other 
cause. 

PERINEORRHAPHY  WHEN  THERE  IS  NO  RECTOCELE. 

For  some  days  previous,  the  patient  should  live  on  a 
diet  calculated  to  secure  a  daily  soft  evacuation  from 
the  bowels,  and  remove  any  hard  scybalous  masses 
which,  if  passed  within  a  few  days  after  the  operation, 
might  impair  union.  Dr.  Thomas  recommends  a  mild 
laxative  to  secure  two  evacuations  per  day  for  the  same 
reason. 

The  preparation  of  the  patient  and  the  room  is  the 
same  as  for  a  laceration  of  the  cervix  uteri,  except 
the  foot  of  the  table  is  not  raised.  The  patient  is  placed 
in  the  lithotomy  position,  and  the  second  and  fourth 
assistants  hold  her  knees  under  their  right  and  left  arms 
respectively,  so  as  to  leave  both  hands  free  to  assist  the 
operator.  The  knees  can  also  be  secured  by  using 
the  crutch,  a  padded  instrument  which  holds  the  knees 

'  Hegar  und  Kaltenbach,  p.  750.  '  Emmet,  p.  399. 


88 


LACERATION  OF   THE   PERINEUM. 


at  the  desired  distance  apart,  and  keeps  them  flexed  on 
the  abdomen  by  a  loop  passing  from  the  crutch  or  stick 
under  one  arm  and  the  back  of  the  neck.  This  can  be 
improvised  from  a  stout  broomstick,  cotton  wadding, 
and  a  sheet. 


Fig.  40.    Crutch  for  the  Knees. 

The  necessary  instruments  are:  — 

2  pair  scissors  (Emmet's),  slightly  curved,  for  the  right  and 

left  hands. 
I  pair  scissors,  sharp-pointed,  straight,  and  slightly  curved  on 

the  flat. 
4  fine  tenacula  (3  Sims',  i  Emmet's). 
I  mouse-toothed  forceps. 
6  Plan's  artery  forceps. 
6  sponge-holders,  and  1 2  small  fine  sponges,  as  for  trachelor- 

rhaphia.^ 
I   Russian  needle-holder. 

'  See  note  in  regard  to  this  reference,  p.  87. 


PERINEORRHAPHY   WITHOUT  A    RECTOCELE.     89 


Fig.  41.    Pean's  Artery  Forceps. 


90 


LACERATION  OF   THE  PERINEUM. 


9  straight,  7-oimd-pointed  needles,  with  large  sunken  eyes 
(i  i-in.,  3  ij-in.,  2  i|^-in.,  2  if-in.,  i  2-in.,  and  i  small 
curved  needle  for  introducing  superficial  silk  sutures)  ; ' 
all,  excepting  the  last,  threaded  as  for  trachelorrhaphia.^ 


16  strands   No.  26    silver  wire,    10  in.  long,  arranged   as   for 
trachelorraphia  ; '  some  fine  silk.^ 

^  Catgut  is  used  by  some  operators  as  a  continuous  suture  in  plastic  operations 
on  the  vagina,  especialiy  when  it  is  desirable  to  operate  on  the  perineum  at  the 
same  time.  It  is  prepared  by  immersing  it  in  the  essential  oil  of  juniper  for  thirty- 
six  to  forty-eight  hours,  and  then  keeping  it  in  a  tei>  per  cent  solution  of  glycerine 
and  alcohol.     It  must  not  be  alloived  to  touch  water  at  any  time. 

2  Compare  note  in  regard  to  this  reference,  p.  87. 

3  A  good  way  to  make  the  silk  antiseptic  is  to  dip  it  in  melted  parafifine  containing 
five  per  cent  of  carbolic  acid,  and  allow  it  to  cool. 


PERINEORRHAPHY  WITHOUT  A  RECTOCELE.    91 


I  counter-pressure  hook. 

I  Emmet's  twisting-forceps. 

I  wire  scissors. 

I  Sims'  shield. 

12  perforated  shot  with  clean  holes. 

I  shot-compressor. 


codman  &  shtjbtiibfp,  boston. 

Fig.  49.    Scissors  cukved  on  the  Flat. 


codman  &  shurtlefp,  boston. 

Fig.  50.     Counter-Press  re  Hook. 


codman  &  shiieti.eff,  boston. 
Fig.  51.    Solid  Tenaculum. 


The  patient  is  placed  in  the  lithotomy  position  as 
previously  described,  her  hips  flush  with  the  edge  of 
the  table,  and  a  sponge  or  towel  tucked  between  the 
buttocks  to  catch  any  blood  which  may  collect. 

An  assistant  on  either  side  retracts  the  labium,  the 
fingers  being  placed  at  exactly  opposite  points,  and 
using  the  same  amount  of  traction  ;  otherwise  the  field 
of  operation  thus  exposed  is  distorted.  If  the  laceration 
be  quite  recent,  the  scar  and  discoloration  at  once  show 
where  the  tear  took  place,  and  indicate  the  area  to  be 
freshened.  In  long-standing  cases,  which  are  very  rare 
without  a  small  rectocele,  the  discoloration  and  scar 
have  almost  always  disappeared.  In  these,  the  two 
sides  or  halves  of  the  perineum  must  be  symmetrically 


92 


LACERATION  OF   THE   PERINEUM. 


freshened  and  brought  together.  (Figs.  52,  53,  54.) 
Each  side  is  similar  to  a  triangle,  Fig.  52,  R  B  C  R'. 
The  base  line  B'  R  B  begins  at  the  lower  caruncula  on 


Fig.  52. 

This  represents  the  area  of  denudation  lying  perfectly  flat  with  sutures  inserted.  A,  anus; 
RR',  median  line  over  rectum,  perpendicular  of  triangle;  RB  and  R  B',  outer 
margins  of  freshening,  nearly  parallel  with  labia,  base  of  triangle;  B  C  R',  upper 
margin  of  freshening  in  the  vagina,  the  approximate  hypotenuse  of  the  triangle;  dd, 
ee,ff,  gg,  hh,  the  sutures,  to  be  inserted  in  order  of  the  lettering. 

either  side,  and  never  extends  farther  out  on  the  labia 
than  this,  as  it  would  then  include  loose  areolar  tissue 

B 


KiG.  53. 


Diagram  of  a  section  in  the  median  line  through  the  perineum,  after  it  is  drawn  together^ 
and  the  sutures  twisted.  Lettering  as  in  Fig.  52.  B  R'  shows  how  the  suture  hh 
draws  together  the  loose  tissue  in  dotted  line  B  C  R'. 

which  never  entered  into  the  formation  of  the  perineum, 
which  can  give  no  support,  and  which  would  only  cause 


PERINEORRHAPHY  WITHOUT  A  RECTOCELE.   93 

discomfort.  Art  must  not  unite  here  what  nature  never 
does.  The  apex  line  C  R' C  lies  in  the  vagina  usually 
from  an  inch  to  an  inch  and  a  quarter  above  the  line 
B'RB,  and  corresponds  to  the  lower  margin  of  that 
place  where  the  posterior  wall  ceases  to  be  firm,  and 
is  relaxed  and  flabby. 


f-^,'^ 


Fig.  54. 

Letters  same  as  in  Fig.  52.     Diagram  of  freshened  surface  extending  out  on  the  labia  more 
than  in  Fig.  52.' 

Having  ascertained  the  amount  of  surface  to  be 
denuded,  the  operator  begins  by  marking  out  its  bound- 
aries. He  inserts  the  Sims*  tenacula  at  the  points 
B',  R',  B,  hands  them  to  the  assistants,  who  put  B  R' 
on  the  stretch  ;  this  raises  a  ridge  in  a  straight  line 
between  them.  The  operator  picks  up  the  crest  of  the 
ridge  at  B  with  Emmet's  tenaculum  or  the  mouse-tooth 
forceps,  and,  with  the  right-curved  scissors,  removes  it 
in  a  fine  continuous  strip,  to  R';  the  latter  point  is 
then  put  on  a  stretch  with  B',  and  the  denuded  strip 
continued  to  this  point  ;  lastly,  B'  B  is  put  on  the 
stretch,   and   the    strip  denuded,   with   the    left-curved 


'  The  reader  will  understand  these  diagrams  better  by  cutting  similar  figures 
out  of  stiff  paper,  and  folding  them  in  line  R  R',  and  bringing  points  B  B' together. 


94  LACERATION  OF   THE  PERINEUM. 

scissors,  to  B.  If  the  operator  be  ambidextrous,  he  can 
remove  strips  from  right  to  left,  and  vice  versa,  till  the 
denudation  is  complete.  This  is  rapidly  done,  and  any 
points  which  bleed  profusely  can  be  seized  with  the 
artery -forceps.  The  surface  should  then  be  examined 
for  any  little  undenuded  places,  and  one  additional  short 
strip  taken  off  at  the  points  C,  C,  on  either  side  ;  this 
gives  the  curves  to  the  lines  B'  C  R'  and  B  C  R',  and 
allows  the  relaxed  fascia  and  vaginal  tissues  to  be  drawn 
up,  like  the  mouth  of  a  bag  with  a  running-string,  by 
the  suture  hh,  and  restores  it  to  the  normal  condition. 
See  Fig.  53,  slack  tissue  in  line  B  C  R' drawn  into  B  R'. 

There  are  two  important  things  to  be  borne  in  mind 
in  freshening  the  perineum.  First,  the  beginner  is  very 
apt  to  freshen  too  much  ;  it  is  better  to  freshen  too 
little  at  first,  and  enlarge  the  area  later  if  necessary : 
secondly,  freshen  as  Hghtly  as  possible,  over  the  rectal 
wall,  by  making  the  strips  very  narrow  and  thin,  and 
keeping  the  curve  of  the  scissors  flat  on  the  surface ; 
while,  at  the  sides,  it  is  a  good  plan  to  remove  the  loose 
cellular  tissue  more  freely,  so  as  to  bring  the  muscular 
fibres  into  closer  apposition.  Very  superficial  freshening 
is  advised  where  the  surface  is  blue  and  thickly  streaked 
with  veins. 

No  attention  need  be  given  to  moderate  oozing. 
Hemorrhage  is  readily  controlled  by  the  artery-forceps, 
compression  between  finger  in  rectum  and  thumb  on 
the  vaginal  surface,  or  introducing  and  drawing  up  the 
sutures.  It  is  almost  never  necessary  to  ligate  a  vessel. 
The  sutures  are  now  introduced,  beginning  at  the  anal 
margin.  The  operator  inserts  the  forefinger,  and,  if 
necessary,  the  middle  finger,  into  the  rectum,  and  draws 
the  anterior  wall  forward,  so  as  to  put  all  parts  of  the 
denuded  surface  in  nearly  the  same  plane,  and  to  feel, 
between  the  thumb  and  finger,  the  course  of  the  point 


PERINEORRHAPHY  WITHOUT  A   RECTOCEIE.    95 

of  the  needle,  which  must  never  be  allowed  to  penetrate 
the  rectum. 

An  assistant  bends  one  end  of  the  silver  wire  sharply 
down  on  the  silk  loop  '  of  one  of  the  smaller  needles, 
which  is  inserted  one-fourth  of  an  inch  from  the  lower 
margin  of  the  wound,  carried  the  same  distance  up  in 
the  line  R  R',  between  the  left  thumb  in  the  vagina, 
and  the  finger  in  the  rectum,  and  made  to  emerge  at  a 
corresponding  point  on  the  opposite  side,  aided  by  the 
counter-pressure  hof)k  or  the  left  thumb. 

The  remaining  sutures  are  inserted,  in  like  manner, 
about  one-fourth  of  an  inch  apart,  as  shown  by  the 
dotted  lines  in  Figs.  52  and  54.  The  last  suture  hk,  or 
the  binding  suture,  is  the  most  important  of  all,  and 
brings  all  the  margins  of  the  wound  together.  The 
point  of  the  needle  is  first  deeply  thrust  directly  back- 
ward and  upward,  so  as  to  obtain  a  firm  hold  on  the 
muscular  fibres,  and  great  care  taken  to  pass  it  behind 
the  sulcus  of  the  wound  on  either  side  without  allowing 
the  point  to  emerge  anywhere  on  the  surface.  Another 
suture  is  often  inserted  above  this  one  and  the  line  of 
denudation,  to  take  off  any  strain.  It  is  passed  through 
nearly  half  an  inch  of  tissue,  on  either  side,  near  B  and 
B',  comes  out  on  the  vaginal  surface,  and  picks  up  a 
similar  amount  on  the   posterior  wall   just    above    R' 

(Fig.  55.//)- 

After  the  sutures  are  inserted,  and  crossed  over  to 
opposite  sides  to  see  if  the  perineum  comes  together 
nicely,  the  surfaces  are  separated,  and  thoroughly 
sponged  with  hot  carbolized  water  to  remove  the 
coagula  and  bits  of  fibrine,  and  the  knees  loosened  so 
that  the  soles  of  the  feet  rest  on  the  edge  of  the  table. 

^  Take  a  piece  of  fine  silk  eighteen  inches  long  ;  thread  both  ends,  in  opposite 
directions,  through  the  eye  of  the  needle,  and  then  tie  a  half  hitch  with  one  of  the 
ends,  or  twist  them  with  the  loop  near  the  needle. 


96  LACERATION  OF   THE   PERINEUM. 

This  relaxes  the  perineum.  The  sutures,  beginning 
with  the  one  next  to  the  anus,  are  then  shouldered, 
twisted,  and  the  loops  drawn  out  where  they  enter  the 
skin,  the  same  as  in  trachelorrhaphy/  A  perforated 
shot  is  crushed  on  each  suture  one-eighth  of  an  inch 
from  the  loop,  and  the  wire  cut  off  close  over  it.  If  the 
shot  is  applied  close  to  the  loop,  the  skin  becomes 
eroded  around  it.  The  perineum  is  again  cleansed  with 
carbolized  water  or  with  a  solution  of  corrosive  sub- 
limate I  :  4,000,  smeared  with  calendula  cerate  ;  and, 
finally,  the  knees  are  loosely  bound  together  with  a 
folded  towel  between  them. 

The  after-treatment  is  simple.  The  diet  should 
consist  of  soups,  gruels,  and  milk,  which  will  nourish 
the  system  without  leaving  much  residue.  The  patient 
is  allowed  to  evacuate  the  bowels  at  any  time  ;  but, 
at  an  intimation  of  a  desire  to  do  so,  the  nurse  is 
instructed  to  administer  a  small  enema  of  oil  to  soften 
the  movement,  and  the  patient  urged  to  retain  it  a 
couple  of  hours  for  that  purpose. 

The  urine  is  passed  in  a  bed-pan  without  a  catheter  ; 
but,  immediately  afterward,  the  knees  are  elevated  close 
together,  and  a  stream  of  carbolized  water  is  allowed  to 
flow  gently  over  the  parts,  from  a  fountain  syringe,  and 
cleanse  the  wound,  taking  care  to  keep  the  nozzle  close 
to  the  urethra,  and  away  from  the  line  of  union.  After 
this,  the  calendula  cerate,  in  a  melted  form,  can  be 
dropped  over  the  wound  with  a  small  piston-syringe. 
These  douches  must  be  given  morning  and  night  if 
there  is  any  discharge,  otherwise  they  are  unnecessary. 
The  patient  is  instructed  to  lie  perfectly  qtiiet  during 
the  first  forty-eight  hours  after  the  operation,  so  as  to 
secure  union  by  primary  adhesion  if  possible.  The  less 
important  stitches  near  the  anus,  or  every  other  one, 

^  See  chapter  on  Trachelorrhaphy. 


PERINEORRHAPHY  WITH  A  RECTOCELE.        97 

are  removed  on  the  eighth  day,  the  rest  on  the  tenth  or 
twelfth. 

To  do  this,  place  the  patient  on  the  table  as  for 
operating,  with  the  knees  together  and  raised  over  her 
abdomen.  Seize  the  shot  with  anatomical  forceps,  raise 
it  gently  till  the  shining  silver  loop  is  seen,  cut  the 
latter  on  one  side  close  to  its  entrance  to  the  tissues,  and 
draw  the  shot  towards  that  side  in  order  not  to  drag  on 
the  wound.  Cutting  the  wire  at  the  point  of  entrance  is 
important  ;  otherwise  the  end  which  is  drawn  through 
is  sharply  bent,  forming  a  little  hook,  and  causes  much 
pain.' 

The  patient  is  again  put  to  bed,  and  the  knees  loosely 
bound  together.  If  unian  has  progressed  favorably,  she 
can  sit  up  on  the  fourteenth  day,  and  go  about  her 
room  in  three  weeks  ;  but  she  must  be  cautioned  not  to 
allow  any  strain  on  the  parts,  by  certain  positions,  or 
otherwise,  for  two  months  after  this  period.  Posterior 
displacement  of  the  uterus  is  particularly  injurious  at 
any  time  for  some  months  after  the  operation  ;  and 
particular  attention  must  be  given  to  prevent  it,  or  the 
operator  will  have  done  his  work  to  no  purpose. 

PERINEORRHAPHY    WITH    A    RECTOCELE. 

This  is  the  more  common  operation  by  far  ;  as  a 
laceration  of  the  perineum  of  long  standing  is  usually 
accompanied  by  a  rectocele,  or  bulging  of  the  posterior 
vaginal  wall  into  the  site  of  laceration.  Under  these 
circumstances,  the  rectocele  must  be  obliterated  by 
including  its  anterior  portion  in  the  operation  so  as  to 
take  up  the  slack,  and  unite  the  torn  fascia  and  muscular 
fibres  ;  again,  if  the  lower  portion  of  the  perineum  were 
closed,  leaving  the  rectocele  bulging  over  and  above  it 

'  See  p.  io6  for  coil  suture. 


98  LACERATION  OF   THE  PERINEUM. 

in  the  vagina,  the  projection  of  the  posterior  wall  would 
continue  to  increase  till  the  new  perineum  became 
involved,  stretched  out,  and  rendered  useless. 

The  position  of  the  patient,  the  instruments,  the  as- 
sistants, freshening,  and  suturing  are  essentially  the 
same  as  in  the  operation  just  described,  as  well  as 
the  after-treatment.  There  are,  however,  three  things 
which  deserve  special  mention. 


Fig.  55. 

Shows  area  of  denudation  for  laceration  of  perineum  with  rectocele.  V,  vagina ;  C,  anal 
margin  of  laceration;  R,  crest  of  rectocele;  A  and  B,  upper  margins  of  freshening, 
extending  a  little  out  on  the  labia,  near  the  lower  carunculae;  aa,  bb,  cc,  dd,  ee,_ff, 
sutures  lettered  in  order  of  their  introduction. 


First,  it  is  important  to  accurately  map  out  the  limits 
of  denudation.  To  do  this,  pick  up,  with  a  fine  Sims' 
tenaculum,  three  points  at  A,  R,  and  B,  Fig.  55,  which 
will  come  together  readily,  without  much  traction,  just 
below  the  urethra.  A  and  B  correspond  to  points  near 
the  lowest  caruncula  or  vestige  of  the  hymen  on  either 
side ;  R,  to  a  point  in.  the  median  line,  near  the  crest  of 


PERINEORRHAPHY   WITH  A    RECTOCELE.     99 

the  rectocele,  which  is  easily  brought  forward  to  A  or  B. 
Snip  a  bit  of  tissue  off  at  each  of  these  places,  to  mark 
the  limits  of  freshening. 

Secondly,  much  care  is  necessary  in  freshening  the 
sulcus  (S)  on  either  side  of  the  rectocele,  in  order  to 
have  the  margins  come  accurately  together  without 
traction,  as  these  may  be  said  to  form  the  buttresses  of 
the  perineum  ;  a  very  common  mistake  is  to  remove  too 
much  tissue  at  these  places  on  the  sides  of  the  vagina. 


Fig.  s6. 

Diagram  of  a  section  of  the  perineum  through  the  median  line.  C,  anal  margin ;  D,  upper 
angle  of  perineum;  DC,  rectal  wall;  H  R  C,  dotted  line  of  rectocele;  R,  crest  of 
rectocele  carried  up  to  R',  the  crest  of  the  new  perineum,  which  brings  dotted  line 
H  R  into  D  R',  obliterating  the  rectocele,  and  making  it  the  vaginal  surface  of  the  new 
perineum. 

Thirdly,  in  introducing  the  sutures,  as  indicated  by 
dotted  lines  a,  b,  c,  d,  e,  and  f,  Fig.  55,  it  is  important 
that  all,  excepting  a  and  f,  are  passed  deeply  (three- 
eighths  inch),  at  the  sides,  beneath  the  sulcus  {e  and  f 
excepted),  and  superficially  over  the  surface  of  the  rec- 
tum without  penetrating  it.  The  point  of  the  needle 
is  made  to  emerge  at  the  desired  spot  by  pressing  on 
the  tissues  with  the  counter-pressure  hook  or  with  the 
thumb  of  the  left  hand. 

This  may  seem  a  little  difficult ;  but  if  the  operator 
introduces  the  fore  and  middle  fingers  of  the  left  hand 
in  the  rectum,  draws  it  forward  nearly  flush  with  the 
surface,  and  enters  the  needle  fully  one-third  of  an  inch 
from  the  margin  of  the  wound,  directing  it  first  a  little 
upward   and    backward,   turning   the   point   across   the 


lOO 


LACERATION  OF  THE  PERINEUM. 


rectocele,  only  when  the  point  reaches  the  sulcus,  by 
rotating  the  zvrist,  the  needle-holder,  and  depressing  the 
head  of  the  needle  at  the  same  time,  and  never  by  twisting 
on  the  shaft  of  the  latter,  there  will  be  very  little  trouble 
in  passing  the  sutures  properly  or  from  breaking  needles. 
Sutures  a  and  b  require  a  needle  i^-i|-  inch  long  ; 
c,  d,  and  e,  i|-i|,  rarely  2  inches.  When  these  are 
united,  and  the  perineum  restored,  the  lines  AC  and 
B  C  meet  in  the  median  line,  and  R  is  brought  forward 
to  unite  with  A  and  B,  Fig.  55.  It  will  be  seen, 
therefore,  that  the  lines  R  S  and  S  A  come  in  contact. 
Compare  Figs.  56  and  57. 


Fig.  57. 


This  diagram  represents  the  perineum  viewed  from  above  when  drawn  together  by  sutures. 
(Only  y  and  e  are  shown.)  Compare  Figs.  55  and  56.  S,  S,  upper  margins  of  sulci; 
RR,  crest  of  rectocele  brought  forward  to  A,  B,  upper  margins  of  freshening;  e,/, 
two  upper  sutures. 


The  details  and  after-treatment  will  be  readily  under- 
stood by  reference  to  the  former  operation  of  perineorr- 
haphy. 

Before  describing  a  second  method  of  perineorrhaphy 
complicated  by  rectocele,  known  as  Emmet's  new  opera- 
tion, it  may  be  well  to  consider  one  form  of  laceration 
which  is  particularly  liable  to  lead  to  this  condition.  It 
is  a  familiar  fact  to  most  observers,  that  laceration  of 
the   perineum    does    not    generally  take    place   wholly 


"i -SHAPED  LACERATIONS. 


lOI 


in  the  median  line.  The  upper  half  leads  off  to  one 
side  of  the  rectum,  and  the  lower  forms  irregular  sur- 
faces near  the  perineal  raphe.  Sometimes  the  advan- 
cing head  lifts  the  perineal  structure  off  the  anterior 
surface  of  the  rectum,  and  then  splits  it,  forming  a  Y- 
shaped  laceration  (comp.  Fig.  57)  ;  in  the  first-mentioned 
case,  one  or  the  other  arm  of  the  Y  would  be  wanting. 
In  both,  not  only  is  the  so-called  perineal  body  torn,  but 


VL 


Fig.  58. 

Diagiam  showing  Y-shaped  laceration  previously  alluded  to.     V,  vagina ;  V  L,  crescentic 
line  of  vaginal  laceration;  P  L,  perineal  laceration ;  A,  anus. 


also  the  fascia  and  muscular  fibres.  This  weakens  the 
posterior  vaginal  wall,  which  is  no  longer  taut,  but  slack, 
relaxed,  and  weakened.  It  bulges  forward,  and  faecal 
masses  during  straining  at  stool  increase  it,  owing  to  the 
posterior  curve  of  the  rectum  at  this  place.  The  lacer- 
ated surfaces  retract,  contract,  and  undergo  involution, 
so  that  the  ragged  edges  become  smooth,  with  at  most 
only  a  nodule,  or  carunculas  as  their  traces  (comp. 
Figs.  58  and  59). 


102 


LACERATION  OF   THE   PERINEUM. 


The  previous  method  of  operating,  which  may  be 
termed  Emmet's  old  operation,  is  much  simpler  and 
more  easy  of  execution  than  his  new  one  about  to  be 
described.  The  latter  is  rather  more  effectual,  and  the 
vaginal  sutures  close  the  wound  more  perfectly.  The 
arrangement  and  insertion  of  the  sutures,  and  limiting 
the  outer  line  of  denudation  to  the  original  margin  of  the 
perineum,  never  extending  it  on  the  labia,  are  the  dis- 
tinctive features  of  the  new  operation  ;  though  its  great 
aim  is  to  unite  the  divided  fascia  and  muscular  fibres. 


Fig.  59- 

Effect  of  laceration  in  Fig.  57.     V,  vagina;    R,  rectocele;    S  S,  sulci  on  either  side  of  the 
rectocele;  D,  lower  margin  of  the  laceration;  A,  anus. 


The  preparation  of  the  patient,  the  arrangements, 
freshening,  suturing,  and  after-treatment,  etc.,  are  essen- 
tially the  same  as  in  the  operation  first  described,  and 
need  not  be  repeated.  The  needles  should  be  of  some- 
what   different    size,   from   4    inch    to    i 


inches   long. 


While  I  have  always  used  silver  wire,  I  am  inclined 
to  believe  that  silk  sutures  dipped  in  melted  paraffine 
containing  five  per  cent  carbolic  acid,  and  allowed  to 


EMMET'S  METHOD   OF  PERINEORRHAPHY.     103 

cool,  have  some  advantages,  and  are  less  annoying  to  the 
patient. 

The  limits  of  denudation  (Fig. '60)  are  marked  out  in 
the  following  manner.  Near  the  crest  of  the  recto- 
cele,  some  point,  R,  is  selected,  which  is  easily  brought 
forward,  without  traction,  to  B  and  C,  which  correspond 
to  the  lowest  caruncula  on  either  side.  These  are 
snipped  off  as  the  limits  of  denudation.     If  the  points 


Fig.  60. 

Diagram  of  perineal  laceration  with  rectocele,  showing  the  shape  of  denuded  area  with  the 
vaginal  sutures  in  place  on  one  side.  V,  vagina;  R,  point  near  crest  of  rectocele 
brought  forward  and  upward  to  unite  with  B  and  C ;  B  C,  highest  points  of  freshening 
at  the  sides,  corresponding  to  the  lowest  carunculse  or  vestiges  of  the  hymen;  S, 
sulcus;  D,  lowest  margin  of  laceration  just  within  the  muco-cutaneous  line;  A,  anus; 
aa,  bb ,  cc,  dd,  ee,  sutures. 


R  and  C  (Fig.  60)  are  brought  together  by  tenacula 
with  slight  traction,  they  will  form  two  ridges,  or  folds, 
extending  up  in  the  vagina  and  meeting  at  S.  These 
are  the  superior  margins  of  two  triangular  surfaces  to 
be  denuded,  one  side,  R  S,  corresponding  to  the  recto- 
cele ;  the  other,  C  S,  to  the  lateral  vaginal  wall  ;  the 
base   of  the  former  lies   in   the  median   line  over  the 


I04  LACERATION  OF   THE   PERINEUM. 

rectum,  and  the  base  of  the  latter  in  the  line  C  D  ; 
while  both  surfaces,  or  triangles,  unite  at  the  groove  or 
sulcus  S  D. 

The  line  C  D  B  extends  from  the  lower  caruncula  on 
either  side  along  the  junction  of  the  skin  and  mucous 
membrane,  but  never  out  on  the  loose  areolar  tissue  of 
the  labia. 

The  two  triangles  C  S  D  and  R  S  D  on  this  side  are 
freshened,  taking  great  care  that  they  are  perfectly- 
symmetrical,  and  the  sutures  inserted  (comp.  Fig.  60), 
but  not  twisted  or  tied  till  the  opposite  side  is  treated 
in  like  manner,  unless  it  is  evident  from  the  scar  or 
otherwise  that  only  one  side  is  torn.  Then,  of  course, 
only  that  side  need  be  freshened.  The  vaginal  sutures 
are  put  in,  beginning  at  the  upper  angle,  by  sticking 
the  needle  in  -^^  inch  from  the  margin,  bringing  it  out 
in  the  sulcus,  inserting  it  again  at  the  place  of  exit, 
and  making  it  emerge  at  a  point  corresponding  to  its 
original  insertion  on  the  opposite  margin  ;  their  order 
and  course  through  the  tissues  are  shown  by  letters  aa, 
bb,  cc,  dd,  ee  (Fig.  60).  When  these,  ee  excepted,  are 
brought  together,  they  lie  in  a  crescentic  line  (Fig.  61) 
in  the  vagina,  and  out  of  sight  when  the  labia  are  not 
separated,  and  the  two  triangles  on  each  side  are  united. 
The  lines  C  S  and  R  S  unite  on  one  side,  and  R  S  and 
B  S  on  the  other.  B  D  and  C  D  are  also  brought  in 
apposition,  but  require  three  or  four  superficial  sutures, 
D  B  (Fig.  61).  The  suture  ee  (Fig.  60)  is  an  important 
one,  and  is  designed  to  take  off  the  strain  in  a  measure 
from  the  others. 

Dr.  Emmet  does  not  consider  it  necessary  to  use  the 
catheter  after  this  operation,  though  he  advises  it  in 
the  previous  one.  A  vaginal  douche  immediately  after 
micturition  is  necessary,  keeping  the  tube  close  to 
the    urethral    orifice,    so    that   it   neither   touches,   nor 


THE    COIL   SUTURE. 


105 


directs  a  powerful  stream  of  water  against,  the  line  of 
union. 

While  it  is  not  considered  necessary  to  tie  the  knees 
after  this  method  of  operating,  I  am  accustomed  to  do  so 
for  a  few  days,  to  make  doubly  sure  of  good  union,  and 
to  enjoin  absolute  rest  and  quiet  during  the  first  forty- 
eierht  hours. 


Fig.  61. 

Diagram  of  points  B,  C,  and  R,  brought  together,  showing  the  effect  of  the  operation  in 
restoring  the  perineum  to  its  original  form,  and  crescentic  line  of  union  in  the  vagina. 
Comp.  Fig.  57.  V,  vagina;  S,  S,  extreme  upper  angles  of  the  sulci;  a,  h,  c ,  d,  position 
of  these  sutures  when  twisted;  e  is  not  figured;  B,  C,  R,  D,  and  A,  same  as  in  Fig.  60. 


The  superficial  sutures  can  be  removed  on  the  ninth 
or  tenth  day;  but  it  is  better  to  leave  the  vaginal  till  the 
twelfth,  as  they  are  often  difficult  to  get  at  without  drag- 
ging on  the  new  perineum.  It  must  often  be  done  by  the 
sense  of  touch,  though  the  smallest-size  Sims'  speculum 
inserted  beneath  the  pubic  arch  helps  to  expose  them. 

The  coil  suture  obviates  many  of  the  difficulties  met 
with  in  finding  and  removing  the  ordinary  silver  suture. 
It  is  made  as  follows  :  Take  the  ordinary  silver  wire, 


Io6  LACERATION  OF   THE  PERINEUM. 

leave  one  inch  from  the  end  straight,  and  then  coil  it 
closely  around  an  ordinary  No.  6  egg-eyed  sewing  needle 
till  the  coil  is  at  least  a  quarter  of  an  inch  long,  and  cut 
the  wire  ten  inches  from  the  coil.  The  long  end  of 
the  wire  is  bent  over  the  silk  loop,  and  introduced  in  the 
usual  way.  When  the  suture  is  to  be  fastened,  pass 
the  long  end  of  the  wire,  the  bent  end  being  cut  off, 
through  the  centre  of  the  coil,  and  slip  a  perforated  shot 
over  the  ends  of  both  wires  close  up  to  the  coil,  crush 


Coil. 


Suture  ready  ior  introduction.  Long  end.  Suture  ready  for  shot  at  A. 

Fig.  62.    The  Coil  Suture. 

it,  and  cut  off  the  ends  of  the  wire  close  over  it.  When 
the  suture  is  to  be  removed,  cut  the  coil  just  behind  the 
shot,  seize  the  coil  with  the  forceps,  and  draw  it  out ; 
the  end  within  the  coil  at  once  slips  out,  and  the  suture 
is  easily  removed  without  hunting  for  the  loop,  and 
interfering  with  the  line  of  union.  Furthermore,  there 
are  no  ends  of  wire  to  prick  the  patient,  and  the  shot  is 
not  as  likely  to  erode  the  tissues  as  when  it  is  crushed 
close  to  the  surface. 

The  reader  will  find  further  details  in  the  method  of 
operating  first  described,     (See  p.  90.) 


ABSCESS  OF   THE  LABIA,   ETC.  107 


CHAPTER   VII. 

ABSCESS    OF    THE    LABIA,    AND    PHLEGMONOUS 
INFLAMMATION    OF    THE    VULVA. 

THESE  affections  are  so  similar  to  each  other,  they 
are  considered  together,  as  their  treatment  is 
essentially  the  same.  It  will  be  noticed,  that  not  only 
abscess  of  the  vulvo-vaginal  (Bartholini's)  gland,  but 
also  of  the  cellular  tissue  about  the  introitus  vagincE, 
is  included  by  these  names.  The  former  is  much  the 
more  frequent  of  the  two  affections. 

The  abscess  is  most  often  caused  by  some  traumatism, 
such  as  excessive  coitus,  pruritus,  and  is  not  infrequently 
associated  with  vulvitis.  The  diagnosis  is  easy.  The 
patient  complains  of  pain,  on  walking,  especially  during 
the  sexual  act,  and  a  sensation  of  localized  heat  and 
throbbing.  On  physical  examination,  one  of  the  labia 
is  swollen,  usually  at  or  near  the  vulvo-vaginal  gland. 
The  surface  of  the  swelling  is  reddened,  and  very  sensi- 
tive to  the  touch  ;  if  pus  has  already  formed,  fluctuation 
will  be  present. 

The  treatment  for  abscess  of  the  labia  is  the  same  as 
for  an  abscess  in  any  other  part  of  the  body.  When 
there  is  distinct  fluctuation,  the  question  of  opening  it 
demands  our  consideration.  Barnes  and  Schroeder 
recommend  an  early  incision.  Guerin  and  Martineau 
have  seen  fistulae  follow  too  early  an  operation.  Thomas 
and  others  believe  that  the  evacuation  of  pus  can  be 
left  to  nature  unless  the  pain  is  very  severe. 


IO§  ABSCESS   OF  THE   LABIA,   ETC. 

It  is  a  safe  rule,  however,  that,  where  pointing  and 
fliictnation  are  distinct,  the  abscess  shonld  be  lanced  in 
a  direction  nearly  parallel  with  the  smaller  labium,  as 
the  pus  is  hable  to  burrow  beneath  the  fascia  if  not 
evacuated. 

Abscess  of  the  perineum,  on  the  contrary,  requires 
opening  as  soon  as  fluctuation  is  perceptible,  as  here 
the  pus  is  likely  to  burrow,  and  fistulse  will  be  the 
result.  In  either  case,  it  may  be  necessary  to  keep 
the  incision  open  by  a  cloth  tent  or  bit  of  charpie. 

When  abscess  of  the  vulvo-vaginal  gland  frequently 
returns,  or  tends  to  become  chronic,  the  sac  must  be 
opened  freely,  thoroughly  cleansed,  and  stuffed  with 
lint  smeared  with  calendula  cerate,  so  that  the  cavity 
will  heal  from  the  bottom.  The  dressing  must  be 
renewed  once  in  twelve  to  twenty-four  hours,  according 
to  the  amount  of  secretion.  If  this  treatment  be 
unsuccessful,  the  gland  can  be  extirpated,  though  Dr. 
Thomas  states  that  he  has  never  found  it  necessary. 

After  an  abscess  has  been  opened,  it  is  advisable  to 
wash  it  out  with  lukewarm  water,  adding  some  of  the 
non-alcoholic  tincture  of  calendula  in  the  proportion  of 
two  tablespoonfuls  to  a  pint  of  water.  Either  a  little 
stronger  solution,  or  the  calendula  cerate,  applied  after- 
wards on  a  piece  of  linen,  and  covered  with  oiled  silk, 
makes  an  excellent  dressing. 

Frequent  poulticing  is  advisable  in  the  beginning. 
Flaxseed  holds  the  heat  better  than  slippery  elm  or 
oatmeal,  but  is  more  liable  to  become  rancid.  The  skin 
must  be  freely  oiled,  and  the  addition  of  ten  to  twenty 
drops  of  the  tincture  of  opium  or  belladonna  to  the 
poultice  just  before  it  is  applied  will  diminish  the  pain. 

Dry  heat  from  hot-water  or  bran  bags  will  also  give 
relief,  and  hasten  suppuration. 


THERAPEUTICS  OF  LABIAL  ABSCESS,   ETC.     109 
THERAPEUTICS, 

I  Belladonna,  also  arnica  at  the  commencement.  If  the 
swelling  be  slight,  the  skin  only  reddened,  and  no  pus  present, 
the  free  use  of  the  tincture  locally  may  disperse  it.  It  is 
indicated  by  severe  throbbing  pain  before  pus  has  formed, 
headache,  and  much  constitutional  disturbance. 

Apis.  Recommended  by  Dr.  Hughes  for  inflammation  of 
the  vulvo-vaginal  gland. 

Arsenicum.  Violent  pains  and  burning  during  the  febrile 
stage;  chills,  fever,  and  consecutive  sweat ;  secretion  of  offensive 
matter  tinged  with  blood ;  muscular  prostration,  restlessness, 
tendency  to  terminate  in  gangrene. 

Asafoetida.  Chronic  cases.  Discharge  of  discolored  and 
thin  matter ;  pus  profuse,  greenish,  thin,  offensive,  or  ichorous  ; 
parts  extremely  painful  to  the  touch. 

Calc.  carb.  In  scrofulous  persons  and  chronic  cases,  or 
after  suppuration  is  completed  ;  pain  shght  if  any. 

I  Hepar  sulph.  Excellent  to  promote  suppuration.  Ab- 
scess very  sensitive  to  contact,  easily  bleeding ;  burning,  stinging 
pain  ;  discharge  corrosive,  smells  like  old  cheese  ;  little  pimples 
surround  the  principal  opening.  Also,  if  the  process  of  sup- 
puration be  very  slow,  nux  vomica  might  be  useful,  as  it  has 
been  recommended  for  anthrax. 

I  Mercurius  viv.  If  the  abscess  be  blennorrhagic  (Kali 
iod.)  ;  chilliness,  with  thirst,  and  nocturnal  aggravation  of  the 
pains ;  also  worse  from  the  heat  of  the  bed ;  abscess  painful, 
with  a  copious  discharge  of  thick  matter.  It  is  very  useful  to 
hasten  suppuration  when  it  is  inevitable. 

Phosphorus.  If  there  are  fistulous  openings  (SiUcea), 
with  burning  and  stinging,  watery,  offensive  discharge  ;  chronic 
cases. 

I  Phytolacca.  Recommended  by  Dr.  Ludlam  as  the  best 
internal  remedy  for  simple  non-specific  abscess  of  the  vulvo- 
vaginal gland. 

I  Silicea.  If  the  discharge  is  copious,  too  protracted,  and 
unhealthy ;  tendency  to  become  chronic  ;  fistulous  openings. 
(Phos.) 


no  ABSCESS  OF   THE  LABIA,   ETC, 

Sulphur.  If  suppuration  is  prolonged,  and  to  prevent  the 
recurrence  of  abscesses  or  boils. 

Before  suppuration.     Aeon.,  bell.,  '>nerc.  viv. 

During  suppuration.  Ars.,  asafoetida,  china,  hepar 
sulph.,  lachesis,  mere,  viv.,  silicea,  phosphorus,  Phyto- 
lacca. 

After  sjippuration.  Calc.  carb.,  china,  phos.  ac,  sul- 
phur, silicea. 

General  vital  depression,  and  tendency  to  gangre7te. 
Arsenicum,  crotalus,  lachesis,  phosphoric  acid. 


VULVITIS. 


Ill 


CHAPTER   VIII. 


VULVITIS.  —  VAGINITIS. 


INFLAMMATION  of  the  vulva  is  not  infrequently 
associated  with  vaginitis,  though  either  one  may  be 
independent  of  the  other.  It  has  the  same  character- 
istics as  inflammation  of  the  mucous  membrane  else- 
where, and  has  been  subdivided  into  a  variety  of  forms 
for  convenience  of  description,  as  in  the  following  table. 
The  most  common  causes  are  over-indulgence  of  the 
sexual  appetite,  and  gonorrhoeal  infection. 


Form. 


Etiology. 


Symptoms  and  Diagjiosis. 


Prognosis. 


Simple 
acute  vulvi- 
tis. 


Acute  vir- 
ulent vulvi- 
tis. 


Local  irritation 
from  traumatism,  ex- 
cessive venery ,  over- 
exercise,  uncleanli- 
ness,  or  masturba- 
tion. The  presence 
of  some  other  dis- 
ease, such  as  vagin- 
itis or  cancer. 

Is  the  result  of 
specific  infection. 


The  parts  at  first  are  hot  and 
dry,  but  soon  become  bathed  with 
a  muco-purulent  secretion  which 
has  an  acid  re-action.'  The  mu- 
cous membrane  is  red,  somewhat 
swollen,  and  excoriated.  Some 
pain  on  motion.  Occasionally 
there  is  intense  pruritus;  more 
rarely,  painful  micturition.  As  a 
rule,  there  is  no  febrile  action. 

If  the  disease  has  developed  soon 
after  impure  connection,  there  is  a 
profuse  discharge  of  thick  yellow 
or  greenish  pus  of  an  offensive  na- 
ture, which  excoriates  the  thighs. 
Urethritis  is  often  present,  and  va- 
ginitis. The  disease  develops  rap- 
idly, and  infects  any  mucous  mem- 
brane brought  in  contact  with  it. 
Labial  abscess  is  a  common  compli- 
cation. Great  care  must  be  taken  not 
to  introduce  the  virus  within  the  eye. 


Is  readily  cured. 


Good,  if  prop- 
erly treated. 


'  Dr.  Martineau  places  much  stress  on  the  presence  of  the  gonococcus  in  the 
vaginal  discharge,  and  of  the  acid  re-action.     He  thinks  gonorrhoea  very  rarely 


112 


VUL  VITIS.  —  VA  GINITIS. 


Form. 


Etiology. 


Symptoms  and  Diagnosis. 


Prognosis. 


Gangren- 
ous vulvitis. 


Diphtheri- 
tic vulvitis. 


Follicular 
vulvitis. 


Vulvitis  in 
children. 


E  ru  p  t  ive 
diseases  of 
the  vulva 
(eczema) . 


It  is  sometimes  a 
complication  of  puer- 
peral septicaemia, 
severe  cases  of  scar- 
let fever,  measles, 
and  continued  fever. 
It  is  probably  due  to 
a  depraved  condition 
of  the  blood,  and  low 
vitality  of  the  system. 

Occurs  during  an 
epidemic  of,  or  com- 
plicates, diphtheria. 
It  is  really  diphtheria 
of  the  vulva. 

Uncleanliness, 
pregnancy,  vaginitis, 
eruptive  diseases, 
excessive  venery. 


May  be  the  result 
of  violation,  but  is 
more  often  due  to  a 
scrofulous  diathesis, 
ascarides,  uncleanli- 
ness, or  dentition. 


The  vulva  is  sub- 
ject to  the  same 
eruptive  diseases  as 
other  parts  of  the 
body,  and  from  the 
same  causes.  Ec- 
zema is  one  of  the 
most  common. 


Severe  constitutional  symptoms, 
and  dark-colored  swollen  labia. 
A  patch,  or  vesicle  of  purplish 
hue,  ulcerates  with  indurated  red 
margins.  This  becomes  the  seat 
of  gangrene,  which  steadily  ad- 
vances, and  discharges  an  ichorous 
fffitid  fluid  if  the  disease  is  not 
arrested. 

It  may  be  confounded  with  the 
preceding  form,  but  is  distin- 
guished by  the  patches  of  false 
membrane  resembling  wash- 
leather. 

There  is  an  increased  secretion 
from  the  glands,  with  burning, 
itching,  heat,  and  soreness  between 
the  labia.  The  sensitiveness  may 
be  so  great  as  to  cause  vaginismus. 
The  mucous  membrane  is  red, 
slightly  elevated  in  patches,  hav- 
ing the  appearance  of  swollen  villi, 
which  bleed  easily;  or  there  are 
little  red  prominences  scattered 
over  the  vulva,  which  soon  break 
down,  discharge  a  small  quantity 
of  pus,  and  may  leave  small  ulcer- 
ated points. 

If  due  to  violation,  signs  of 
traumatism  are  present,  and,  dur- 
ing twenty-four  hours  afterwards, 
spermatozoa  may  be  found  in  the 
vaginal  secretions.  The  affection 
is  less  severe  than  the  forms  pre- 
viously described,  and  is  usually 
of  an  aphthous  character. 

Eczema  of  the  vulva  chiefly 
affects  the  skin,  and,  to  a  less 
extent,  the  mucous  surface.  In- 
tense pruritus  is  a  prominent  symp- 
tom. There  is  also  redness,  heat, 
and  numerous  little  vesicles  which 
break,  and  discharge  a  serous, 
sticky  fluid.  In  chronic  cases, 
crusts  or  scales  may  form.  Ex- 
amine the  urine  for  sugar. 


Fortunately 
this  is  a  rare  dis- 
ease, as  a  large 
proportion  of 
these  cases  ter- 
minate fatally. 


A    few    cases 
recover. 


Is  liable  to 
become  chronic, 
and  then  difficult 
to  cure.  If  caused 
by  pregnancy,  it 
will  almost  al- 
ways terminate 
with  it. 


Favorable. 


It  is  sometimes 
an  obstinate 
affec  t  ion,  and 
difficult  to  cure 
permanently. 


extends  to  the  uterus.     He  found  only  ten  instances  of  it  in  four  thousand  cases 
of  gonorrhoea,  —  Amiales  de  Gynecologie,  July,  1885. 


TREATMENT  OF   VULVITIS.  II3 

The  Diet.  —  Highly  seasoned  food  should  be  avoided. 
In  the  gangrenous  form,  the  importance  of  an  abundance 
of  nutritious  food  and  pure  air  cannot  be  over-estimated. 

Local  Treatment.  —  Pruritus  is  often  one  of  the  most 
distressing  symptoms,  for  the  treatment  of  which  the 
reader  is  referred  to  the  chapter  on  that  subject. 
Cleanliness  is  of  the  utmost  importance.  Vaginal  or 
vulvar  douches  of  tepid  water  may  be  used  one  to  four 
times  a  day,  according  to  the  source  and  amount  of  the 
secretion.  After  the  latter  has  been  washed  away,  one 
of  the  following  medicated  douches  is  beneficial :  — 

CALENDULA.  Four  teaspoonfuls  of  the  tincture, 
but  preferably  a  non-alcoholic  preparation,  to  a  pint  of 
tepid  water,  if  the  mucous  surfaces  are  raw  and  excori- 
ated. 

HYDRASTIS.  Same  proportion  as  the  calendula.  Is 
preferable  for  profuse  muco-purulent  secretion.  It  can 
also  be  applied  in  powder,  with  an  ordinary  insect- 
powder  gun. 

KREOSOTE.  Ten  to  thirty  drops  to  a  pint  of  water 
is  a  good  application  for  severe  pruritus,  biting  and 
smarting  of  the  labia,  a  profuse  and  offensive  discharge. 

CORROSIVE  SUBLIMATE.  Three  grains  dissolved 
in  a  pint  of  water  is  the  strongest  solution  which  should 
be  used  on  a  raw  surface.  Compressed  tablets  of 
corrosive  sublimate  are  very  convenient  for  this  pur- 
pose. It  is  a  favorite  with  many  for  severe  pruritus, 
also  for  a  greenish  purulent  offensive  discharge.  Cases 
of  a  specific  origin. 

PLANTAGO  AND  BORACIC  ACID  CERATE  is  worthy 
of  a  trial  where  the  inflammation  is  of  an  aphthous  type. 

NITRATE  OF  SILVER.  Five  to  thirty  grains  to  the 
ounce.     In  very  virulent  cases  of  specific  origin,  after 


1 14  VUL  VITIS.  —  VA  GINITIS. 

other   means    fail.       Compare    method    of    using    it    in 
chapter  ii.,  p.  32. 

After  bathing,  dry  the  parts  carefully  with  a  soft 
linen  cloth  if  they  are  not  too  sensitive,  and  place 
between  the  labia  a  small  piece  of  linen  or  absorbent 
cotton  smeared  with  vaseline,  fresh  lard,  or  mutton 
tallow.  This  prevents  friction  of  the  inflamed  surfaces 
if  the  patient  is  obliged  to  walk  about.  If  the  discharge 
from  the  vulva  is  excoriating,  the  surrounding  skin  can 
be  protected  by  some  simple  ointment  such  as  vaseline. 

In  the  acute  stage,  where  there  is  no  secretion,  the 
mucous  membrane  dry  and  hot,  with  burning  and 
itching,  dusting  on  a  little  powdered  corn-starch  will 
be  grateful  to  the  patient.  If  the  inflammation  be  more 
severe,  with  swelling,  throbbing,  and  pain,  a  warm 
poultice  of  linseed  meal,  bread  and  milk,  or  grated 
potato,  should  be  applied. 

In  gangrenous  vulvitis.  Dr.  Thomas  states  that  a 
powerful  caustic,  such  as  the  actual  cautery  or  nitric 
acid,  is  the  only  hope.  As  soon  as  a  gangrenous  spot 
appears,  it  must  be  destroyed  by  this  means,  and  a 
disinfectant  poultice  employed.  Dr.  Parrot,  however, 
recommends  the  free  use  of  iodoform  in  powder.  For 
the  treatment  of  eczema  and  erythema  of  the  vulva,  the 
reader  is  referred  to  the  chapter  on  pruritus  vulvae. 

Although  local  treatment  is  often  an  excellent  adju- 
vant, it  cannot  take  the  place  of  a  carefully  selected 
remedy.  The  medical  treatment  is  considered  in  the 
following  chapter  on  vaginitis,  as  the  two  diseases  are 
not  infrequently  associated  with  each  other,  are  similar 
in  character,  and,  in  both,  the  same  mucous  membrane 
is  affected,  though  in  a  little  different  locality. 


VAGINITIS. 


115 


VAGINITIS. 

This  is  an  inflammation  of  the  mucous  membrane  of 
the  vagina,  and  has  also  been  described  under  the  name 
of  vaginal  leucorrhoea.  It  is  most  often  the  result  of 
excessive  venery  or  specific  infection.  The  different 
forms  are  briefly  described  in  the  following  table  :  — 


Form. 


Etiology. 


Symptoms  and 
Diagnosis. 


Complications 
or  SeguelcE. 


Prognosis. 


Simple  va- 
ginitis may 
be  acute  or 
chronic,  pri- 
mary or  sec- 
ondary. 


Exposure  to  cold 
and  dampness, 
abuse  of  sexual 
intercourse,  acute 
eruptive  diseases; 
local  irritation 
from  pessaries,  re- 
tention of  bits  of 
sponge,  cotton 
tampons,  chemical 
agents,  irritating 
discharge  from 
uterys,  or  exten- 
sion of  inflamma- 
tion from  the  vulva 
(in  the  last  two 
instances,  the  va- 
ginitis is  second- 
ary); parturition. 


There  is  burning,  heat, 
or  throbbing  in  the  va- 
gina; sometimes  severe 
pelvic  pain;  a  variable 
araoimt  of  offensive, 
purulent  leucorrhoea  ; 
excoriations  about  the 
vulva  ;  an  aching  and 
sensation  of  weight  in 
the  perineum;  frequent 
micturition.  In  the  in- 
ception of  the  disease, 
the  mucosa  is  hot  and 
dry,  but  there  is  usually 
within  twenty-four  hours 
an  acrid  discharge,  which 
becomes  muco-purulent 
later,  with  swollen,  hot 
labia.  There  is  great 
sensitiveness  to  contact, 
and,  if  an  examination 
be  made  with  the  specu- 
lum, the  mucous  mem- 
brane is  found  red,  and 
congested  with  abrasions, 
or  there  are  small  ulcer- 
ated points  on  the  sur- 
face. In  the  chronic  form, 
the  red,  injected  mucosa 
and  leucorrh(£al  dis- 
charge may  be  the  only 
symptoms. 


Very  rarely  it 
may  assume  a 
phlegmonous 
form,  and  termi- 
nate in  abscess. 
It  may  extend 
to  the  urethra, 
and  very  rarely 
to  the  endome- 
trium. Fallopian 
tubes,  and  pelvic 
peritoneum.  It 
may  become 
chronic,  and 
cause  relaxation 
with  consequent 
prolapse  of  the 
vaginal  walls.' 


Good. 


Schroeder,  Kratik.  d.  weibl.  Geschlechtsorgane,  p.  473,  18S1. 


ii6 


VUL  VITIS.  —  VAGINITIS. 


Form. 


Etiology. 


Specific 
vaginitis  or 
gonorrhoea. 


Granular 
vaginitis. 


Is  always  the 
result  of  specific 
infection. 


May  result  from 
either  of  the  pre- 
ceding forms,  but 
is  almost  always 
associated  with 
pregnancy,  and  li- 
able to  re-appear 
in  successive  preg- 
nancies. 


Symptoins  and 
Diagnosis. 


It  may  be  exceedingly 
difficult  to  distinguish 
from  the  preceding  form, 
but  the  foUowmg  symp- 
toms point  to  it:  Marked 
purulent  urethritis  is 
often,  but  not  always, 
present,  and  a  profuse 
yellow,  or  greenish-yel- 
low, vaginal  discharge 
having  an  acid  re-action; 
the  severity  and  rapid 
development  of  the  dis- 
ease in  a  woman  pre- 
viously free,  or  nearly 
so,  from  vaginal  dis- 
charges. All  these  symp- 
toms may  very  rarely 
exist,  however,  in  non- 
specific vaginitis,  but,  in 
the  latter,  the  gonococcus 
is  never  found  by  the 
microscope.  In  this  dis- 
ease, it  sometimes  hap- 
pens, that,  for  a  length 
of  time,  only  the  posterior 
fornix  of  the  vagina  is 
affected.  This  accounts 
for  the  fact  that  women 
apparently  healthy  may 
transmit  gonorrhoea. 

The  subjective  symp- 
toms are  similar  to  those 
of  simple  vaginitis.  On 
examination,  the  finger 
feels  numerous  granula- 
tions, like  fine  millet 
seed,  scattered  over  the 
mucous  membrane  and 
cervix  uteri.  It  bears 
the  same  relation  to  sim- 
ple vaginitis  that  follicu- 
lar vulvitis  does  to  the 
ordinary  form  of  vulvitis. 


Cotnplications 
or  Seg2iel<E. 


Buboes,  cys- 
titis, abscess  of 
the  vulva.  Is 
much  more  like- 
ly than  the  pre- 
ceding form  to 
extend  upwards 
to  the  endome- 
trium. Fallopian 
tubes,  and  pelvic 
peritoneum, 
with  a  fatal  is- 
sue. 


None. 


Prognosis. 


Good  if 
properly 
treated,  and 
no  complica- 
tions. Ac- 
cording to 
Dr.  Noegge- 
rath,'  how- 
ever, a  per- 
manent cure 
without  se- 
quelae is 
questionable. 


Good.  The 
disease  usu- 
ally termi- 
nates with 
pregnancy. 


'  Die  latejite  Gono7-rkoe  im  -weiblichen  Geschlecht,  Bonn. 


TREATMENT  OF    VAGINITIS. 


117 


Form. 

Etiology. 

Symptoms  attd 
Diagnosis. 

Co7nplications 
or  Sequela. 

Prognosis. 

Adhesive 

Is  found   in  el- 

It tends  to  form  adhe- 

Adhesions 

Good. 

or  senile  va- 

derly women  after 

sions  between  the  vaginal 

may  result,  but 

ginitis. 

the  climacteric. 

walls,  or  with  the  cervix, 
and  is  found  in  the  upper 
thirdof thevagina.  There 
may    be    no    subjective 
symptoms  whatever.    In 
other  cases,  the  mucous 
membrane  bleeds  easily, 
and  the  leucorrhoeal  dis- 
charge   is    tinged    with 
blood,  which  might  give 
rise     to     suspicion     of 
malignant  disease  if  an 

are  not  likely  to 
be     of     serious 
import. 

examination  be  not  made. 

The  diet  and  local  treatment  are  the  same  as  in 
vulvitis.  After  each  vaginal  injection,  a  roll  of  cotton 
or  oakum,  saturated  in  glycerine  and  a  few  drops  of 
impure  carbolic  acid,  must  be  inserted  in  the  vagina 
to  keep  the  inflamed  surfaces  apart.  Dr.  Emmet 
recommends  a  teaspoonful  of  chloride  of  ammonium 
to  each  pint  of  hot  water  as  a  vaginal  douche ;  and,  if 
there  be  much  heat  and  swelling,  the  addition  of  a  few 
spoonfuls  of  alcohol  to  increase  the  evaporation  and 
lower  the  temperature.  A  paste  of  fuller's  earth,  made 
with  water  and  a  little  glycerine,  has  been  used  success- 
fully in  severe  cases  of  vaginitis.  The  vagina  is  filled 
and  the  external  parts  covered  with  it.  When  this 
earth  poultice  becomes  dry  and  irritating,  it  is  washed 
out  with  a  syringe  and  replaced  by  another.  Dr. 
Martineau '  has  had  good  results  in  the  treatment  of 
chronic  vaginitis  by  salicylic  acid  mixed  with  powdered 
gum-arabic  and  wheat  flour,  as  follows  :  — 

B     Salicylic  acid 3  parts. 

Wheat  flour 5  parts. 

Powdered  gum-arabic      .     .     .     .     i  part. 

I  Medical  News,  April  12,  1884, 


1 1 8  VUL  VITIS.  —  VA  GINITIS. 

It  is  applied  by  an  insufflator  to  all  the  vaginal  surface. 
The  favorite  application  for  chronic  inveterate  vaginitis, 
and  especially  for  the  specific  form,  is  a  strong  solution 
of  nitrate  of  silver,  twenty  grains  to  the  ounce,  rarely 
stronger.'  The  preparation  is  poured  into  a  shallow 
dish  ;  and  with  the  aid  of  a  Sims'  speculum,  and  a  small 
cotton  swab  on  a  stick,  it  is  applied  to  the  cervical 
canal  and  entire  mucous  membrane  of  the  vagina  and 
vulva,  coating  it  white  by  the  formation  of  the  albu- 
minate of  silver.  The  pain  is  only  temporary.  As 
soon  as  the  surfaces  are  dry,  they  should  be  covered 
freely  with  vaseline,  and  a  small  long  tampon  introduced 
thoroughly  smeared  with  the  same  substance.  Vaginal 
douches  followed  by  fresh  vaginal  dressings  must  be 
repeated  two  or  three  times  a  day.  This  measure  is  a 
severe  one,  and  should  not  be  resorted  to  until  after  a 
reasonable  trial  other  means  fail  to  relieve.  Martineau 
has  found  a  moderately  strong  solution  of  corrosive 
sublimate  (i  :  i,ooo)  very  useful  as  a  local  application. 

'  THERAPEUTICS    OF    VULVITIS    AND    VAGINITIS. 

Aconite.  Baehr  believes  the  use  of  aconite  is  merely  a 
loss  of  time,  and  recommends  the  use  of  mere.  sol.  or  mere, 
viv.  at  once.  Other  careful  observers,  however,  report  good 
results  from  this  remedy.  It  is  best  suited  to  the  non-specific 
variety  resulting  from  cold,  and  especially  in  the  beginning  of 
the  attack.  The  vagina  is  dry,  hot,  and  sensitive  (Bell.) ;  painful 
urging  to  urinate  ;  and,  in  some  cases,  when  the  menses  have 
been  suddenly  suppressed,  there  co-exists  acute  ovaritis. 

I  Arsenicum.  Dr.  Imbert  Goubeyre  ^  showed  that  this 
drug  has  a  marked  elective  affinity  for  the  vulva ;  and  Dr. 
Hughes  relies  on  it,  in  preference  to  any  other  remedy,  for  the 
treatment  of  vulvitis,  shooting  pains  from  the  abdomen  into 

'  See  chapter  ii.,  p.  32. 

^  British  Journal  of  Horn.,  vol.  xxiii. 


THE  RAP.    OF    VULVITIS  AND    VAGINITIS.     I  IQ 

the  vagina,  burning  tensive  pains  in  the  ovary,  especially  the 
right,  profuse  yellow  thick  {^Hydrastis,  kali  bi.)  corroding 
leucorrhoea  (Kali  carb.). 

Calc.  carb.  Scrofulous  diathesis.  Profuse  sweat  about 
the  labia ;  stinging,  burning  tubercles  on  the  margin  of  the 
labia;  aching  in  the  vagina,  violent  itching  and  soreness  of 
the  vulva,  inflammation  and  swelling  of  the  genitals  (Asaf., 
canth.);  leucorrhoea  like  milk  (Carb.  veg,,  conium,  lye,  puis., 
sepia,  sulph.ac),  with  itching  and  burning. 

Cantharis.  Swelling  and  irritation  of  the  vulva  (Asaf., 
calc.  carb.);  violent  itching  in  the  vagina  (Conium,  mere); 
pruritus,  with  strong  sexual  desire  ;  if  the  inflammation  involve 
the  urethra,  with  severe  dysuria  (Cannabis  sat.). 

Carbo  veg  Aphthous  inflammation  of  the  mucous  mem- 
brane (Graphites,  helonias),  which  itches,  and  is  sore  and  raw 
during  leucorrhoea ;  thin,  milky,  excoriating  leucorrhoea  (Ars., 
coni.,  kreos.,  lye,  puis.,  sepia)  only  in  the  morning  on  rising ; 
varices  of  the  vulva.  This  remedy  is  particularly  suited  to  old 
people. 

I  Kreosote.  Burning  between  the  labia  on  urinating  ; 
soreness  between  the  thighs  and  vulva,  with  burning,  biting 
pains  (Sepia)  ;  soreness  and  smarting  between  the  labia ; 
violent  itching  of  the  labia,  also  of  the  vagina  (Canth.,  conium) ; 
external  genitals  swollen,  hot,  hard,  and  sore;  yellow  leucor- 
rhoea, with  great  weakness,  staining  linen  yellow  (Carb.,  an.). 

I I  Merc.  sol.  Inflammation  of  the  vagina,  and  especially 
of  the  external  genitals,  with  rawness,  smarting,  and  excoriated 
spots  (Carb.  veg.,  graph.,  helonias) .  Leucorrhoea,  always  worse 
at  night,  greenish  discharge,  smarting,  corroding,  itching,  burn- 
ing after  scratching  (Alum,  coni.,  phos.,  puis.);  itching  of  the 
genitals,  worse  from  the  contact  of  the  urine. 

Rhus  tox.  Ecze??ia  of  the  vulva  (Graph.,  hepar  sulph., 
mez.,  sulph.),  pruritus,  vesicles,  or  crusts ;  soreness  and  pain  in 
the  vagina ;  external  genitals  inflamed,  erysipelatous. 

I  Sepia.  Great  dryness  of  the  vulva  and  vagitia  ;  painful 
to  the  touch ;  itching  eruption  on  the  nymphse,  which  are  red 
and   swollen ;    ?nuch   weight  and  bearing-dowti   of  the  pelvic 


1 20  VUL  VITIS.  —  VA  GINITIS. 

organs.  Leiicorrhoea,  yellow,  milky  (Calc.  carb.,  coni.,  lye, 
sulph.  ac,  puis.),  excoriating  {Alum,  ars.,  kreos.,  sulph.),and 
especially  before  the  menses. 

Sulphur.  Profuse,  yellowish,  corrosive  leucorrhoea  {Alum, 
ars.,  kreos.,  sepia) ;  burning  in  the  vagina  ;  troublesome  itching 
of  the  genitals,  with  eruption  of  pimples  around  them. 

Thuja.  Condylomata,  moist  bleeding  and  offensive  (Nit. 
ac.) ;  vagina  very  sensitive ;  pains  in  vulva  and  perineum ; 
gleet  following  gonorrhoea. 

Additional  Remedies  for  Consultation.  —  Ambra,  apis, 
arnica,  bell.,  berberis,  cauloph.,  causticum,  cannabis, 
cham.,  china,  cimicif.,  coni.,  croton  tig.,  graphites,  belo- 
nias,  hepar  sulph.,  hydrastis,  kali  carb.,  lach.,  lycop., 
mezereum,  mineral  acids,  nat.  mur.,  nit.  ac,  puis.,  sabina, 
silicea,  staphisagria. 


VAGINISMUS.  121 


CHAPTER    IX. 

VAGINISMUS.  —  ATRESIA.  —  FISTULiE. 

AS  the  name  indicates,  this  affection  consists  in  a 
spasmodic  contraction  of  the  vagina.  The  extreme 
hypersesthesia  of  the  latter  is  most  marked  about  the 
site  of  the  hymen  ;  and  the  mere  touch  of  the  probe, 
or  a  camel's-hair  pencil,  may  be  sufficient  to  induce 
spasmodic  contraction,  and  prevent  further  examination 
without  ether.  It  is  a  symptom  of  some  other  condi- 
tion, rather  than  a  disease  in  itself,  and  is  often  accom- 
panied by  sterility,  as  sexual  intercourse  cannot  be 
endured. 

It  is  most  frequently  associated  with  anaemia  and 
neurasthenia,  hysteria,  pelvic  cellulitis,  uterine  dis- 
placement, urethral  coruncle,  neuromatoid  growths  on 
the  vulvar  mucous  membrane,  excoriations  or  fissures 
about  the  labia  or  anus,  chronic  inflammation  of  the 
endometrium,  vagina,  or  vulva,  and  lead-poisoning. 

The  treatment  should  be  directed  to  the  removal  of 
the  cause  ;  for  unless  this  be  done,  permanent  cure  is 
not  likely  to  follow.  In  addition  the  following  course 
is  recommended.  Complete  sexual  abstinence  is  abso- 
lutely essential  to  success,  and  the  patient's  general 
health  must  be  built  up  as  much  as  possible  if  she  be 
•at  all  anaemic.  For  the  first  few  days,  warm  sitz-baths, 
twice  daily,  and  hot  vaginal  douches  as  soon  as  the 
patient  can  bear  them,  should  be  employed,  and  bella- 
donna or  cocaine  cerate  can  be  applied  to  the  sensitive 


122 


VAGINISMUS.  —  A  TRESIA.  —  FISTULA. 


places  after  each  douche.  In  about  two  weeks  the 
abnormal  sensibility  will  disappear,  and  the  patient  can 
bear  the  presence  of  a  small  Sims'  glass  plug '  for  a 
short  time  each  day.  The  size  of  the  plug,  and  the  time 
it  remains  inserted,  is  gradually  increased  as  the  patient 
can  tolerate  it  without  exciting  an  undue  amount  of 
irritation.  This  is  continued  till  all  signs  of  vaginismus 
have  disappeared.  Scanzoni  states  that  the  cure  will 
be  complete  in  from  six  to  eight  weeks. 


Fig.  63.    Sims'  Glass  Vaginal  Plug. 

Should  the  above  treatment  be  unsuccessful,  Dr. 
Tilt's  method  may  be  tried.  The  operator  anaesthetizes 
the  patient,  introduces  both  thumbs  back  to  back  in 
the  vagina,  and  forcibly  distends  it  for  a  few  minutes. 
A  large  glass  vaginal  plug  is  inserted,  retained  by  a  T- 
bandage,  and  worn  for  a  number  of  days. 

As  a  last  resort  the  knife  can  be  used,  the  hymen 
removed,  and  a  Y-shaped  incision  made  into  the  vaginal 
tissues  according  to  Sims'  method  ;  -  vaginal  dilators 
are  to  be  worn  afterward  as  in  the  previous  methods. 
In  case  of  sterility,  coition  has  been  practised  under 
anaesthesia,  with  the  hope  that  conception  and  parturi- 
tion would  effect  a  cure.     The  prognosis  is  generally 


'  The  author  has  used  instead,  for  purposes  of  dilatation,  a  series  of  very  strong 
glass  test-tubes  beginning  one-half  inch  in  diameter,  and  increasing  each  tube  one- 
sixteenth  inch  till  the  largest  measures  14  inch.  Their  length  makes  them  easier 
to  manipulate  than  Sims'. 

2  Uterine  Surgery,  p.  318. 


THERAPEUTICS  OF   VAGINISMUS.  1 23 

regarded  as  very  favorable,  though  a  high  authority 
declares  that  vaginismus  is  almost  certain  to  return  if 
the  primary  cause  is  not  removed. 

The  medical  treattnent  of  this  affection  is  often  unsat- 
isfactory. In  selecting  the  remedy  the  general  symp- 
toms of  the  patient,  and  those  relating  to  the  cause  of 
the  disorder,  are  of  more  importance  than  the  actual 
hyperaesthesia  and  spasm. 

THERAPEUTICS. 

Caulophyllum.  IVonien  affected  with  rheumatism,  espe- 
cially of  the  smaller  joints.  (Act.  spic,  ledum.)  Sensation 
of  weight,  fulness,  and  tension  in  the  hypogastric  region  {Bell., 
puis.).  Aphthous  vaginitis,  spasmodic pai7is  in  uterus  and  vari- 
ous portions  of  the  hypogastrium  ;  spasmodic  dysmenorrhoea, 
the  pain  being  of  an  intermittent  character.  The  vagina  is 
irritable  and  spasmodic  ;  intense  pain. 

I  Hamamelis.  Vaginismus,  intense  soreness,  prurigo  of 
the  vulva.  Bloody  leucorrhoea,  with  great  tenderness  of  the 
vagina.  Metrorrhagia,  flow  passive,  venous  distension  about 
the  vulva  and  on  the  legs. 

Nux  Vomica.  Menses  too  early  and  profuse,  attended  by 
morning  nausea,  with  chilliness  and  fainting.  Titillation  in 
the  vagina  and  much  nervous  erethism.  Constipation.  Tenes- 
mus of  the  bladder. 

Platina.  Ny7nphomania,  menses  too  early  and  too  profuse. 
Painful  sensitiveness  and  constant  pressure  in  mons  veneris  and 
genital  organs,  genitals  very  sensitive.  Pruritus  vulvae  ;  voluptu- 
ous tingling,  with  anxiety  and  palpitation  of  the  heart. 

I  Plumbum.  Vaginismus,  patients  subject  to  violent  colic 
with  retraction  of  the  abdomen  ;  excruciating  pains  in  umbilical 
region,  with  shooting  to  other  portions  of  abdomen  and  body, 
somewhat  relieved  by  pressure.  Constipatiofi :  stools  hard, 
lumpy,  like  sheep's  dung,  with  urging  and  terrible  pain  from 
constriction  or  spasm  of  the  anus.  Sharp  neuralgic  pains  in 
limbs,  especially  in  muscles  of  thighs  ;  extreme  emaciatioji  ; 
sleeplessness. 


124 


VA GINISMUS.  —  A  TRESIA.  —  FISTULA. 


Pulsatilla.  Crampy  constriction  of  vagina.  Leucorrhcea, 
milky,  thick,  with  swollen  vulva,  painless,  thin,  acrid,  burning. 
Menses  too  late,  scanty,  and  of  short  dm'ation. 

For  further  study  consult :  —  bell.,  cannab.  ind.,  cactus, 
cedron,  cocculus,  coffea,  coni.,  cuprum,'-  ferrmn  acet., 
gels.,  hyosc,  ignat.,  kali  brom.,  lycop.,  macrotin,  mere, 
sepia,  silicea,  thuja,  zinc. 


ATRESIA     OF    THE    GENITAL    CANAL. 

The  closure  of  the  genital  canal  may  be  in  the  cervix 
uteri,  or  any  portion  of  the  vagina.  In  rare  cases,  there 
is  complete  atresia  of  the  entire  vagina  from  arrest  of 
development.  A  fibrous  cord  is  felt  betv^een  the  rectum 
and  bladder,  and,  as  a  rule,  the  uterus  is  rudimentary. 

The  causes  of  atresia  are  :  — 

Congenital  i  Non-development, 

(   Imperforate  hymen ; 
or  [  Syphilis, 

f  Extensive  ulceration,  \  The  local  application  of 
[      chemical  agents  ; 
Acquired     \   Traumatism, 


[  Sloughing, 


'  Parturition, 
Impaired  vitality  from  ty- 
phus  or  scarlet   fever, 
small-pox,  etc. 


The  Diagnosis  is  easy.     The  patient  has  had  no  men- 
strual flow,  though  the  usual  symptoms  attending  the 

'  Mrs. .  has  had  vaginismus  since  first  and  only  pregnancy,  nine  years 

previous.  Spasms  came  on  in  attacks  lasting  from  ten  minutes  to  two  hours,  five 
or  six  times  a  day,  and  vi'ere  almost  continuous  at  the  time  of  the  menses.  Spasms 
severe  enough  to  cause  visible  movement,  and  the  finger  introduced  into  the  vagina 
would  be  clasped  tight  enough  to  numb  sensation  [?].  Cured  in  three  weeks  by 
cuprum  15,  and  remained  so  at  time  of  writing  three  years  afterwards.  —  Dr. 
WiNTERBURN,  A7nerica7i  Horn.,  March,  1884. 


ATRESIA.  125 

menses  have  been  periodically  present.  There  is  also 
disturbance  of  the  nervous  system,  with  backache,  and  a 
sense  of  pressure  on  the  bladder  and  rectum.  Some- 
times there  is  an  obscurely  fluctuating  tumor  in  the 
hypogastric  region.  These  symptoms,  in  girls,  point  to 
an  imperforate  hymen  or  cervical  canal,  with  an  accumu- 
lation of  menstrual  fluid  behind  it.  In  another  class  of 
cases,  the  physician  is  consulted  on  account  of  inability 
to  perform  the  sexual  act,  which  is  not  due  to  vaginis- 
mus. Physical  examination  shows  the  genital  canal 
more  or  less  occluded  in  a  part  or  the  whole  of  its 
course.  With  one  finger  in  the  rectum  and  a  sound  in 
the  bladder,  the  vagina  is  felt  between  them  as  a  fibrous 
cord,  and  sometimes  a  fluctuating  mass  above  it. 

Treatment.  —  If  the  examination  reveals  an  imperforate 
hymen,  with  the  menses  retained  behind  it,  the  mem- 
brane should  be  perforated  with  the  fine  needle  of  an 
aspirator,  and  a  small  quantity  of  the  imprisoned  fluid 
drawn  off,  at  intervals  of  three  or  four  days,  until  the 
cavity  is  emptied  by  as  many  operations.  The  action 
of  the  aspirator  can  then  be  reversed,  and  the  vagina 
washed  out  with  warm  carbolized  water.  After  the 
patient  has  fully  recovered,  the  hymen  can  be  partially 
removed.  The  best  time  for  using  the  aspirator  is  about 
ten  days  after  the  menstrual  symptoms  have  subsided, 
i.e.,  about  midway  between  the  periods. 

The  hymen  should  never  be  incised  with  a  bistoury, 
allowing  the  fluid  to  gush  freely  out,  as  many  fatal  cases 
in  consequence  have  been  recorded. 

For  the  treatment  of  atresia  from  other  causes,  the 
reader  is  referred  to  the  works  of  Drs.  Emmet  '  and 
Thomas.^ 

^  Principles  and  Practice  of  Gynaecology,  p.  188,  1884. 
2  Diseases  of  Women,  p.  220,  1880. 


126         VA  GIN  ISM  US.  —  A  TRESIA .  —  FISTULA. 


FISTULAE. 

The  genital  canal,  i.e.,  the  uterine  cavity  and  vagina, 
may  be  connected  by  one  or  more  apertures,  of  variable 
size  and  shape,  with  the  urinary  tract,  —  i.e.,  the  ureters, 
bladder,  and  urethra,  —  or  with  the  rectum.  These  open- 
ings are  termed  fistulae,  and  named  according  to  the 
parts  connected,  such  as  vesico-vaginal,  uretero-vaginal, 
vesico-uterine,  recto-vaginal  fistula,  etc. 

In  the  great  majority  of  cases,  a  fistula  is  the  result 
of  parturition,  rarely  from  the  unskilful  application  of 
the  forceps  or  the  performance  of  craniotomy,  and 
almost  always  from  delay  in  operating  after  the  pre- 
senting part  has  become  impacted.  The  tissues  lose 
their  vitality,  a  slough  of  varying  extent  ensues,  and  a 
fistula,  which  may  be  no  larger  than  a  pin  or  involve  the 
entire  base  of  the  bladder,  is  the  result.  Fistula  may 
also  follow  an  abscess,  cancerous,  syphilitic,  and  phage- 
denic ulceration  ;  the  latter  more  especially  in  connec- 
tion with  severe  continued  fevers  producing  deficient 
nutrition. 

The  Diagnosis  is  not  dffiicult.  The  continuous  dis- 
charge of  urine,  the  irritation  of  the  vagina,  vulva,  and 
thighs  produced  by  it,  and  the  strong  urinous  odor, 
direct  the  attention  to  a  urinary  fistula;  while,  if  there- 
is  an  escape  of  faeces  into  the  vagina,  especially  during 
an  attack  of  diarrhoea,  the  fistula  is  of  the  fsecal  variety. 
Digital  examination  usually  reveals  the  opening  with  an 
eroded  margin,  giving  a  granular  or  velvety  impression 
to  the  finger.  Very  rarely,  the  fistula  may  be  so  small 
that  the  finger  cannot  detect  it,  and  then  Sims'  specu- 
lum must  be  used  so  as  to  bring  the  vaginal  walls  into 
view.  If  of  the  vesical  variety,  the  bladder  may  be 
injected  with  milk,  which  is  readily  seen  as  it  escapes 
through  the  fistula,  and  indicates  its  site. 


777^    TREATMENT  OF  FISTULAS.  1 27 

The  Treatment  is  entirely  surgical.  In  the  recent 
state,  before  the  urine  has  become  alkaline,  and  there 
are  phosphatic  deposits  on  the  margins  of  the  fistula, 
there  is  a  chance  for  spontaneous  cure  if  the  opening  is 
small.  This  is  very  materially  aided  by  copious  warm- 
water  douches,  twice  or  thrice  daily,  to  which  calendula 
has  been  added,  in  the  strength  of  one  tablespoonful  of 
the  tincture  to  a  pint  of  water.  Though  I  am  not  aware 
that  it  has  been  tried,  it  seems  as  if  the  application  of 
calendula  cerate  to  the  margins  of  the  fistula,  after  each 
douche,  would  be  beneficial.  Not  only  would  it  pro- 
mote the  healing  process,  but  also  protect  the  granu- 
lating surfaces  from  the  urine.  A  mild  solution  of  the 
nitrate  of  silver  can  be  used  occasionally  to  stimulate 
the  edges  of  the  fistula.  If  phosphatic  deposits  are 
present,  they  must*  be  carefully  removed.  The  urine 
should  be  kept  acid  and  diluent,  by  the  use  of  some  acid, 
such  as  benzoic,  and  drinking  water  freely. 

It  is  of  the  utmost  importance  that  the  health  of  the 
patient  be  as  good  as  possible  before  operating.  Plenty 
of  fresh  air,  exercise,  and  a  generous  diet  will  materi- 
ally contribute  to  this,  and  the  success  of  the  operation 
afterwards. 

The  division  of  cicatricial  bands,  etc.,  during  the  pre- 
paratory treatment,  belongs  to  the  surgical  treatment, 
and  will  be  found  in  the  books  referred  to  for  the 
description  of  the  operation.  The  operations  of  Drs. 
Sims'  and  Emmet  ^  do  not  differ  essentially  from  each 
other,  and  deserve  the  preference.  The  latter  has  writ- 
ten one  of  the  most  exhaustive  monographs  ^  on  this 
subject  in  the  English  language,  to  which  the  reader  is 

'  Hewitt's  Diseases  of  Women,  edited  by  H.  Marion-Sims,  vol.  ii.  p.  453, 
1883. 

^  Principles  and  Practice  of  GynEecology,  p.  S17,  1884. 
3  Vesico-Vaofinal  Fistula,  1S68. 


128         VA  GINISMUS.  —  A  TRESIA .  —  FISTULA. 

referred  for  the  reports  of  many  difficult  and  interest- 
ing cases.  Dr.  Bozeman  has  modified  the  operation, 
by  devising  a  new  button  suture,  and  an  apparatus  for 
operating  on  the  patient  in  the  knee-chest  position. 

Few  operators,  however,  have  met  with  more  success 
in  the  treatment  of  this  affection,  than  the  late  Profes- 
sor Gustav  Simon  of  Heidelberg.  His  method  differed 
very  materially  from  that  of  Sims,  and  is  considered  with 
those  of  other  operators  by  Hegar  and  Kaltenbach.' 

'  Die  Operative  Gyndkologie,  p.  596,  18S1. 


_J 


PUBERTY  AND    THE   CLIMACTERIC  PERIOD.     129 


CHAPTER    X. 

PUBERTY   AND    THE    CLIMACTERIC    PERIOD. 

''T^HE  advent  and  close  of  the  menstrual  life  of  a 
X  woman  are  so  often  attended  by  phenomena  pecul- 
iar to  these  periods,  and  distressing  to  the  patient,  it  is 
hoped  that  a  brief  consideration  of  them  may  not  seem 
unnecessary. 

Puberty  is  the  mile-stone  which  marks  the  transition 
from  girlhood  into  womanhood.  During  it,  the  sexual 
organs  undergo  development,  and  menstruation  com- 
mences. With  the  climacteric  period,  or  change  of  life, 
these  conditions  are  reversed ;  the  sexual  organs  atrophy, 
and  the  menstrual  discharge  ceases.  Both  these  periods 
are  influenced  by  climate,  heredity,  and  habits  of  life. 
In  very  warm  climates  the  menses  appear  much  earlier 
than  in  very  cold  countries.  In  some  families,  there  is 
an  hereditary  tendency  to  menstruate  very  early  or  late 
in  life,  and  for  the  discharge  to  be  scanty  or  profuse, 
which  must  be  considered  in  forming  an  estimate  of  the 
normal  condition.  It  is  apparent,  therefore,  that  no 
definite  age  can  be  assigned  as  the  normal  time  for  the 
appearance,  cessation,  duration,  or  the  quantity  of  the 
menstrual  discharge.  The  establishment  of  the  flow, 
however,  is  more  rapid  and  constant  than  the  period  of 
its  cessation.  The  average  age  of  its  appearance  is  four- 
teen years  and  two  months  ;  of  cessation,  between  forty- 
two  and  forty-five  years  ;  and  of  its  duration,  four  days 


I30,   PUBERTY  AND    THE   CLIMACTERIC  PERIOD. 

and  a  half.  The  quantity  varies  so  much  with  different 
individuals,  that  it  is  best  considered  normal  so  long  as 
no  ill  effects  of  any  kind  are  experienced  in  consequence. 

At  puberty,  the  entire  system  feels  the  great  change 
that  is  taking  place  ;  not  only  is  there  active  growth 
and  local  development,  but  there  is  also  called  into  play 
a  remarkable  amount  of  nervous  energy.  This  is  very 
largely  due  to  the  intimate  connection  of  the  ovaries 
with  the  sympathetic  nervous  system ;  hence  it  is  not 
uncommon  for  chorea,  hysteria,  or  even  epileptic  spasms, 
to  appear  at  this  time,  not  to  mention  the  general  con- 
dition of  nervous  erethism.  With  the  establishment  of 
the  menses,  aided  if  necessary  by  proper  medication, 
these  symptoms  usually  disappear. 

Menstruation,  which  is  characterized  by  the  period- 
ical discharge  of  blood  from  the  female  genitals  once  in 
twenty-eight  days,  depends  on  the  ovaries,  and  is  sup- 
posed to  coincide  with  the  rupture  of  a  Graafian  follicle. 
Its  presence,  therefore,  marks  the  child-bearing  period 
in  women,  though  instances  are  recorded  of  impregna- 
tion before  the  first  menses  have  appeared.  The  flow 
of  blood  comes  from  the  uterine  cavity,  the  lining  mem- 
brane of  which  undergoes  fatty  degeneration  once  a 
month,  disintegrates,  and  is  cast  off,  leaving  the  capil- 
laries exposed  and  readily  ruptured,  causing  the  dis- 
charge of  blood.  The  blood  pressure  in  the  capillaries 
and  the  congestion  of  the  pelvic  organs  being  relieved, 
the  flow  ceases  ;  and  the  lining  membrane  of  the  uterus 
is  reproduced  by  the  proliferation  of  cells,  which  were 
beneath  the  former  or  superficial  layer. 

At  the  climacteric  period  the  change  is  retrogressive. 
The  Graafian  follicles  no  longer  ripen  and  cast  off  ova. 
The  menses  become  very  irregular,  and  finally  cease 
to  appear.  While  the  duration  of  this  period  is  very 
variable  in  different  persons,  it  commonly  lasts   from 


PUBERTY  AND    THE   CLIMACTERIC  PERIOD.     I.y 

two  to  four  years.  As  might  be  expected,  nervous  de- 
rangements are  very  common,  especially  those  of  the 
vaso-motor  system.  The  organism  seems  to  contain  a 
superabundance  of  blood,  and  the  patient  suffers  from 
congestive  headaches,  impairment  of  memory,  severe 
flushings  like  hot  water  running  over  her  ;  she  becomes 
over-anxious,  and  is  easily  worried.  Besides  this,  nutri- 
tion may  become  perverted,  leading  to  the  development 
of  fibroids  in  the  unmarried  or  sterile,  and  cancer  in 
fruitful  women,  where  a  severe  laceration  of  the  cervix 
uteri  is  a  focus  of  irritation.  Malignant  disease  may 
develop  in  either  if  there  is  an  element  of  heredity. 
Obesity  is  of  common  occurrence.  Although  this 
"change  of  life"  is  beset  with  many  ailments,  chiefly 
mental,  and  various  neoplasms  are  far  more  likely  to 
develop  then  than  at  any  other  time,  the  patient  will, 
as  a  rule,  enjoy  good, health  afterwards,  if  she  has  taken 
proper  care  of  herself  during  the  climacteric. 

Proper  hygiene  will  do  much  to  relieve  the  various 
complaints  of  women  at  these  periods,  which  mark  the 
rise  and  decline  of  their  greatest  physical  vigor. 

The  periodical  losses  of  blood  to  the  system  at 
puberty,  and  the  demands  for  increased  nutrition,  re- 
quire hearty  food  in  abundance.  Meat,  milk,  and  eggs 
are  important  articles  of  diet.  Fresh  air,  sunshine,  and 
exercise  are  all  necessary  to  the  best  physical  develop- 
ment, unless  we  desire  to  have  our  girls  grow  up  like 
bleached  celery-stalks,  and  unfit  to'  meet  the  responsi- 
bilities of  life.  Not  less  important  at  this  time  is  abso- 
lute physical  and  mental  rest  during  the  monthly  flow. 
If  its  real  value  to  them  in  after-life  could  be  half 
appreciated,  there  would  be  no  grudging  the  time  seem- 
ingly thrown  away.  As  the  hygiene  of  puberty  has 
already  been  discussed  in  the  opening  chapter  of  this 
book,  there  is  no  need  of  repeating  it  here. 


132     PUBERTY  AND    THE    CLIMACTERIC  PERIOD. 

The  hygiene  of  the  climacteric  is  at  once  suggested 
by  the  patient's  condition.  Very  little  beef  is  to  be 
eaten  when  there  are  symptoms  of  local  congestion. 
Eggs,  fish,  poultry,  game,  and  vegetables  are  in  order. 
If  there  is  a  tendency  to  obesity,  which  the  patient 
desires  to  counteract,  all  food  containing  much  starch, 
sugar,  or  milk  should  be  avoided,  and  water  drank  spar- 
ingly if  urea  is  in  excess  ;  fruit,  such  as  oranges,  grapes, 
cherries,  and  berries,  may  be  eaten  ad  libitum,  if  they 
do  not  disagree  with  the  patient.  Plenty  of  exercise  in 
the  sunshine  and  open  air  is  always  advisable.  Pleas- 
ant society,  cheerful  surroundings,  and  enough  to  do 
to  merely  occupy  the  time  without  undue  fatigue,  will 
materially  relieve  the  mental  symptoms. 

Having  briefly  reviewed  the  subject  of  this  chapter 
in  a  general  way,  it  may  be  well  to  consider  here  in 
more  detail  some  of  the  anomalies  characteristic  of  each 
period  of  life. 

Among  the  symptoms  which  precede  the  first  men- 
strual flow  for  weeks  and  even  months,  such  as  dizzi- 
ness, epistaxis,  general  nervousness,  etc.,  the  writer  has 
occasionally  noticed  albuminuria.  While  this  may  have 
been  independent  of  the  age  of  the  patient,  the  fact 
that  the  general  health  was  little,  if  at  all,  affected, 
seemed  to  indicate  that  the  kidneys  participated  in  a 
measure  in  the  congestion  and  hypergemia  of  the  sexual 
organs.  Though  treatment  for  it  is  seldom  necessary, 
further  than  recommending  the  free  use  of  milk  and 
beef,  careful  supervision  of  the  patient,  and  an  occa- 
sional examination  of  the  urine-  for  casts  should  not 
be  neglected,  lest  parenchymatous  nephritis  develop 
unawares. 

Arsenicum,  belladonna,  mercurius  corrosivus,  and 
phosphorus  are  remedies  likely  to  be  beneficial. 


CHLOROSIS.  133 


CHLOROSIS. 


Chlorosis  is  a  disease  found  in  girls  at  or  near  the  age 
of  puberty,  the  most  characteristic  feature  of  which  is 
the  anaemic  appearance  of  the  patient.  Indeed,  the 
resemblance  to  anaemia  is  sometimes  so  close  in  prac- 
tice that  the  dividing  line  cannot  be  drawn  between 
them.  It  gives  a  better  picture  of  the  disease,  to  call 
it  a  special  form  of  anaemia.  Dr.  Flint '  states  that  there 
is  a, reduction  in  the  percentage  of  haemoglobin  of  the 
red  blood  corpuscles,  without  a  corresponding  decrease 
in  the  number  of  the  latter;  and  Virchow  lays  much 
stress  on  the  arrested  development  of  the  vascular  sys- 
tem, particularly  the  aorta.  It  is  believed  to  have  a 
nervous  origin,  as  its  appearance  so  often  dates  from 
some  impression  on  the  nervous  system,  from  the  fre- 
quency of  nervous  symptoms,  hysteria,  etc.,  in  its  early 
development,  and,  finally,  because  those  remedies  which 
are  most  effectual  in  combating  it  are  particularly  adapt- 
ed to  the  treatment  of  nervous  diseases.  Dr.  Ludlam 
lays  much  stress  on  the  importance  of  a  lymphatic  con- 
stitution, and  scrofula,  as  a  predisposing  cause. 

Perhaps  its  most  prominent  symptom  is  amenorrhoea. 
With  this  there  is  a  greenish  pallor  of  the  skin  (hence 
the  old  term  green-sickness)  ;  hysteria  in  some  of  its 
protean  forms,  or  general  nervousness ;  perversion  of 
appetite,  and  morbid  cravings  for  chalk,  slate-pencils, 
pickles,  etc. ;  cardiac  palpitation  and  blowing  sounds  over 
the  heart  and  carotids  ;  headache,  and  a  varying  amount 
of  mental  irritability.  Although  closely  resembling  it, 
chlorosis  should  not  be  confounded  with  the  anaemia 
which  often  precedes  or  accompanies  incipient  tuber- 
culosis in  girls  of  a  scrofulous  habit. 

The  most  reliable  points  of  the  differential  diagnosis 
of  chlorosis  from  anaemia  are,  the  marked  tendency  of 

'  Practice  of  Medicine,  p.  t,'j?>,  1SS4. 


134    PUBERTY  AND    THE   CLIMACTERIC  PERIOD. 

chlorosis  to  relapses,  greenish  pallor  of  the  skin,  the 
frequency  of  fugitive  neuralgic  pains,  nervous  or  mental 
symptoms,  hysteria,  chorea  or  epilepsy,  its  origin  from 
mental  causes,  and  the  absence  of  emaciation.  In  some 
cases,  as  has  been  stated  before,  the  distinction  between 
chlorosis  and  anaemia  is  practically  impossible. 

The  Prognosis  is  favorable,  as  a  rule,  if  the  disease  is 
not  grafted  on  a  scrofulous  constitution  ;  but  it  exhibits 
little  if  any  tendency  to  spontaneous  cure,  and  may 
therefore  last  a  number  of  years  without  treatment. 

The  general  treatment  consists  in  building  up  the 
patient's  health  by  food,  exercise,  etc.,  as  already  de- 
scribed in  the  hygiene  of  puberty. 

THERAPEUTICS. 

Aconite  has  been  mentioned  as  a  remedy  for  chlorosis 
resulting  from  fright ;  and  Dr.  Hempel  thought  well  of  it  for 
the  same  disease  complicated  with  tuberculosis  and  accom- 
panied by  a  sallow  or  greenish  complexion,  deeply  flushed 
cheeks,  palpitation,  dyspnoea,  and  stitches  about  the  chest. 
The  writer  believes  that  constitutional  remedies  would  be 
necessary  intercurrently  with  aconite. 

Argentum  nit.  Dr.  von  Grauvogel '  found  this  remedy 
of  great  benefit  in  affections  characterized  by  shortness  of 
breath  and  cardiac  palpitation,  without  organic  disease  of  the 
heart  or  lungs.  Dr.  Hughes  adds,  sallowness  rather  than  pallor 
of  the  complexion.  A  feeling  of  lassitude,  trembling,  and  the 
tendency  to  muscular  twitchings  or  convulsions  preceded  by 
great  restlessness,  also  point  to  this  remedy. 

I  Calcarea  carb.  is  an  important  constitutional  remedy 
for  girls  of  a  scrofulous  diathesis  with  tendency  to  obesity  and 
glandular  enlargements.  The  girl  has  a  morbid  craving  for 
chalk,  pickles,  etc. ;  takes  cold  easily ;  is  subject  to  acidity  of  the 
mouth  and  stomach,  and  palpitation  of  the  heart  after  eating ; 
though  apparently  strong  and  healthy  from  the  accumulation  of 
fat,  the  muscles  are  weak,  and  she  tires  from  little  exertion. 

'  Lclirbuch  dcr  IJoinboJ>a(hic,  §  271-292. 


THERAPEUTICS   OF  CHLOROSIS.  135 

II  Ferrum.  While  this  is  a  great  remedy  for  anaemia, 
many  physicians  consider  it  equally  good  for  chlorosis.  Dr. 
Hughes  recommends  ferrum  redactum,  ix.  or  2X. ;  Dr.  Jousset, 
ferrum  acet.  or  protoxalate,  ix. ;  and  Dr.  Ludlam  praises  the 
citrate  of  iron  and  strychnia,  3X.,  as  superior  to  either  remedy 
alone.  Dr.  Holcombe  finds  the  phosphate  of  iron  very  useful. 
The  mucous  membranes  are  very  pale,  particularly  of  the  mouth. 
There  is  great  pallor  of  the  face,  with  occasional  sudden  7'ed 
flushes,  with  dizziness ;  ringing  in  ears  ;  palpitation  of  the 
heart ;  dyspnoea,  and  often  chilliness,  with  fever  towards  night 
or  in  the  evening. 

Helonias  has  been  found  a  very  useful  remedy  for  debility, 
or  chlorosis  following  diphtheria.  The  sensation  of  weakness, 
dragging,  and  weight  in  the  sacrum  and  pelvis,  with  great 
languor  and  prostration,  are  also  excellent  indications  for  this 
remedy. 

Ignatia.  When  the  disease  is  due  to  mental  or  emotional 
causes,  with  changeable  disposition,  tendency  to  crying  and 
brooding  over  imaginary  trouble,  in  sensitive  or  hysterical 
women. 

Phosphorus.  Chlorosis,  from  depressing  mental  influ- 
ences, too  rapid  growth,  or  self-abuse  (China),  especially  in 
girls  of  a  tuberculous  habit  (Calc.  carb.),  chronic  cases,  and 
puberty  delayed ;  palpitation  of  the  heart  from  emotion ;  great 
weakness  and  prostration  of  the  whole  system.  She  is  sleepy 
in  day-time,  restless  before  midnight,  and  perspires  easily,  espe- 
cially at  night  while  asleep. 

Plumbum  was  advocated  by  Dr.  Winter '  as  a  remedy  for 
inveterate  chlorosis  with  severe  constipation,  extreme  muscular 
weakness,  variable  pulse,  want  of  breath,  and  great  oppression 
of  the  chest  from  exertion  or  walking.  He  believes  it  aids  the 
action  of  iron,  and  thinks  it  should  precede  it  in  the  treatment 
of  chlorosis  in  early  life,  unless  the  disease  has  been  caused  by 
the  loss  of  blood,  when  iron  must  be  used  first. 

Pulsatilla  was  a  favorite  remedy  for  chlorosis  with  Dr. 
Jahr.  Although  an  excellent  medicine  for  some  of  the  symp- 
toms incident  to  this  disease,  constitutional  remedies  will  be 

'  Brit.  Journal  of  Horn.,  vol.  iii.  p.  278. 


136    PUBERTY  AND    THE    CLIMACTERIC  PERIOD. 

almost  invariably  necessary  to  effect  a  cure.  The  patient  com- 
plains of  chilliness,  or  dry,  burning  heat,  especially  at  night, 
without  thirst.  She  also  suffers  from  palpitation,  drawing,  tear- 
ing pains,  shifting  about  from  place  to  place,  and  feels  better 
in  the  open  air. 

I  Sepia.  Menses  scanty  or  absent ;  great  bearing-down  in 
hypogastric  region  ;  yellow,  milky,  excoriating  leucorrhoea ;  sen- 
sation of  sinking  or  emptiness  of  stomach  (Cimicif ,  ignat.,  pet., 
puis.,  sulph.).  The  patient  suffers  from  hemicrania,  the  pain 
usually  darting  from  the  left  eye,  over  the  side  of  the  head 
toward  the  occiput,  and  is  relieved  by  eating.  There  is  also 
much  bodily  prostration,  and  a  tendency  to  herpetic  eniptions. 

Sulphur  has  many  warm  friends,  both  as  a  constitutional 
remedy  for  chlorosis,  and  as  an  aid  to  the  action  of  other 
medicines.  Dr.  Leadam  praises  it  highly,  and  states  that  he  has 
cured  patients  with  it  in  a  short  time,  after  long-continued 
treatment  with  iron  had  failed.  The  symptoms  which  may  call 
for  it  are  numerous,  but  the  more  important  are  the  following  : 
rush  of  blood  to  the  head,  with  cold  feet ;  pressive  headache 
in  the  morning ;  loss  of  appetite,  with  feeling  of  fulness  in 
the  stomach  after  eating  a  little  ;  constipation  ;  oppression  of  the 
chest ;  palpitation,  especially  at  night ;  frequent  flushes  of  heat ; 
night-sweats,  and  feeling  of  great  prostration  and  weariness. 

The  following  remedies  have  been  recommended  by 
various  physicians.  Ant.  crud.,  arsenicuni  (belladonna), 
(chamomilla),  china,  cimicifuga,  coffea,  conium,  cyclamen, 
ferrocyanuret  of  potassium,  graphites,  kali  carb.,  lycopo- 
dium,  nat.  muriaticum,  nux  vomica,  senecin. 

Some  very  interesting  cures  of  chlorosis  by  calc. 
carb.,  china,  cina,  cyclamen,  ferrum,  graph.,  ignatia, 
ipecac,  nat.  mur.,  nux  vom.,  phos.,  phos.  ac,  puis.,  and 
sepia,  with  additional  remarks  on  some  of  the  remedies, 
can  be  found  in  Riickert's  Klinische  Erfahrimgen,  sup- 
plement, pp.  597-609.  Most  of  them  are  cases  reported 
by  Dr.  CI.  Miiller  in  the  Hoin.  Viertelfalirschrift,  No.  8, 
pp.  428-443- 


CHOREA,   HYSTERIA,  EPILEPSY. 


137 


CHOREA,    HYSTERIA/    OR     EPILEPSY. 

These  affections,  developing  at  or  near  puberty,  prob- 
ably spring  from  the  same  source,  the  extreme  excita- 
bility of  the  nervous  system,  which  is  not  entirely  under 
the  control  of  the  patient.  The  paroxysms  or  attacks 
are  worse  at  or  just  before  the  menstrual  period.  The 
author  wishes  to  emphasize  the  fact  that  hysteria  is  a 
functional  disorder  of  the  nerve-centres,  and  does  not 
depend  on  the  uterus  or  ovaries,  as  was  once  believed, 
though  the  latter  may  not  be  in  a  normal  condition. 

Whatever  the  underlying  causes  are,  they  are  not 
thoroughly  understood  ;  but  the  disorder  is  obvious. 
The  characteristic  features  of  each  are  presented  in  the 
followino-  table  :  — 


Chorea. 


Hysteria. 


Epilepsy. 


Consciousness  not 
lost. 

Muscular  twitch- 
ings  and  tremors 
more  or  less  continu- 
ous. 


Is  less  at  night. 


Consciousness  lost  gradu- 
ally, but  not  complete. 

Complete  intermissions,  with 
attacks  of  sobbing,  laughing, 
sighing,  tonic  and  clonic 
spasms  alternate  ;  less  often 
it  simulates  paralysis  with 
tonic  muscular  contraction. 
Attacks  may  be  preceded  by 
hysterical  symptoms,  but  no 
aura,  epileptic  cry,  foaming  at 
mouth,  or  facial  spasms  ;  the 
pupils  re-act  readily.  Parox- 
ysm not  followed  by  a  semi- 
comatose condition,  but  quite 
constantly  by  the  profuse  se- 
cretion of  pale,  watery  urine. 

Not  common  at  night. 


Consciousness  entirely 
and  immediately  lost. 

Complete  intermissions 
of  apparent  health  between 
attacks  preceded  by  aura. 
With  a  shrill  cry,  the  pa- 
tient falls  unconscious, 
foaming  at  the  mouth,  livid 
face,  distortion  of  counte- 
nance, and  very  little  re- 
action of  the  pupils  to  light. 
Paroxysms  followed  by 
heavy  sleep,  headache,  and 
mental  dulness. 


Occurs  often  at  night. 


'  Dr.  Mary  Putnam  Jacobi  has  made  an  interesting  study  of  hysteria  in  the 
Medical  Record,  Oct.  2,  9,  and  16,  1S86.  For  further  information  concerning  these 
diseases,  the  reader  can  consult  to  advantage  Pepper's  System  of  Medicine,  vol.  v. 


138     PUBERTY  AND    THE    CLIMACTERIC  PERIOD. 

Trance  mid  Catalepsy,  i.e.,  swooning  away  into  an 
apparently  lifeless  condition  for  a  period  varying  from 
a  number  of  hours  to  several  days,  belong  among  the 
curious  manifestations  of  hysteria.  Volumes  might  be 
written  on  this  subject,  but  only  those  forms  likely  to 
be  met  with  at  puberty  will  be  discussed  here. 

The  Prognosis  of  these  various  nervous  anomalies 
depends  on  the  severity  and  regularity  of  the  paroxysms  ; 
as  a  rule,  it  is  favorable,  unless  the  attacks  continue 
after  the  flow  appears  at  regular  intervals.  Epilepsy  is 
the  most  intractable  of  the  three  conditions  mentioned. 

General  Treatment.  —  Mental  rest,  and  the  careful 
avoidance  of  every  thing  which  excites  the  patient,  is 
one  of  the  first  requisites  in  treating  the  case.  General 
hygiene,  as  described  in  the  introductory  chapter,  is 
also  of  great  importance.  Dr.  C.  Hering  made  this 
observation,  that  "  in  all  mental  diseases  it  is  the  most 
sure  sign  of  recovery  if  abscesses  appear,"  How  true 
it  is,  the  writer  is  unable  to  affirm.  The  Faradic  cur- 
rent has  been  successfully  used  for  the  treatment  of 
chorea  and  similar  forms  of  muscular  spasm,  also  to 
rouse  the  patient  from  a  cataleptic  state.  The  brush 
electrode  would  be  useful  to  detect  feigned  epilepsy ; 
for  in  the  genuine  there  is  complete  loss  of  sensation, 
while  if  it  were  feigned  the  pain  excited  by  the  brush 
would  at  once  rouse  the  malingerer.  The  treatment  of 
a  patient  during  an  hysterical  attack  requires  some 
seemingly  harsh  measures.  Be  sure  you  are  right,  and 
then  go  ahead,  is  no  truer  of  any  other  condition  than 
this. 

The  attacks  of  hysteria  are  largely  due  to  a  lack  of 
the  will-power  of  the  patient,  who  gives  way  to  them 
on  slight  provocation,  with  very  little  if  any  attempt 
at  self-control.  The  most  effectual  plan  of  treatment 
is  through  fear,  or  make  the  patient  forget  herself  by 


TREATMENT  OF  HYSTERIA.  1 39 

exciting  her  temper.  Sympathy,  and  the  comforting 
remarks  of  pitying  friends,  are  very  prejudicial  to  the 
welfare  of  an  hysterical  patient.  The  author  refers  only 
to  recent  cases  of  hysteria,  developing  at  or  near  the 
monthlies  in  young  women,  and  not  to  chronic  bed- 
ridden cases  where  the  patient  may  have  really  lost  con- 
trol of  her  will.  In  all  cases,  however,  confidence  in 
her  ultimate  recovery,  if  she  will  earnestly  try,  must  be 
encouraged  ;  and  any  act  or  word  of  the  physician  to 
the  contrary,  so  that  she  loses  faith  in  him,  will  render 
all  his  efforts  unavailing. 

The  following  cases  may  serve  to  illustrate  the  prin- 
ciples of  treatment :  A  professional  friend  was  called  to 
see  a  girl  subject  to  hysteria,  during  one  of  her  attacks. 
Recognizing  it  at  once,  he  called  for  some  red  pepper, 
and  without  any  ado  told  her  to  put  out  her  tongue,  and 
at  once  threw  on  a  pinch  of  the  pepper.  Without  pay- 
ing any  attention  to  the  spitting  of  the  surprised  and 
wrathy  patient,  who  at  once  forgot  her  hysterical  symp- 
toms, he  directed  the  mother,  in  a  very  positive  way,  if 
the  girl  ever  had  another  attack,  to  give  her  a  heaping 
teaspoonful  without  delay.  The  patient  has  not  had 
hysteria  since. 

Another  physician  of  my  acquaintance  was  much 
annoyed  by  a  similar  case.  Asking  the  attendants  to 
leave  the  patient  alone  with  him  a  few  minutes,  he  seized 
her  hand  in  a  firm  grasp  with  the  peremptory  remark, 
"Are  you  not  ashamed  of  this  nonsense .-*  Stop  it  at 
once,  or  I'll  crush  your  hand."  Being  a  man  of  far  more 
than  ordinary  physique,  and  speaking  in  a  very  stern 
manner,  the  desired  effect  was  produced,  and  there  was 
no  further  trouble. 

A  large  number  of  the  patients,  in  a  female  ward 
of  a  well-known  hospital,  were  attacked  with  hysteria. 
It  spread  among  the  cases  like  an  epidemic,  and  there 


I40    PUBERTY  AND    THE    CLIMACTERIC  PERIOD. 

was  no  little  ^difficulty  in  treating  it.  Finally,  the 
attending  physician  had  a  stove  brought  into  the  room, 
a  number  of  cautery-irons  heated  in  it,  and  directed  the 
house-surgeon  to  thoroughly  cauterize  every  case  of 
the  new  disease  the  moment  the  attack  began.  Care 
was  taken  to  make  some  show  of  the  heated  irons,  and 
to  have  each  patient  understand  the  directions  given  in 
regard  to  them.    There  were  no  more  hysterical  attacks. 

It  is  needless  to  add  that  the  teaspoonful  of  red  pepper 
would  not  be  given,  nor  a  patient  injured  or  actually  cau- 
terized ;  but  the  physician  must  make  her  thoroughly 
believe  that  the  measure  will  be  carried  out  in  good 
earnest,  for  the  least  suspicion  of  a  sham  destroys  all 
the  moral  effect. 

The  emetic  properties  of  apomorphia  hypodermically 
have  also  been  used  to  advantage. 

Dr.  Emmet  has  found  the  following  plan  useful  to  cut 
short  an  attack  of  hysteria :  About  an  ounce  of  the 
tincture  of  asafoetida  is  mixed  with  a  basin  of  hot  water, 
and  stirred  up  thoroughly,  close  to  the  patient's  nose. 
This  is  very  likely  to  induce  vomiting,  or  call  forth  some 
protest  from  the  patient,  who  is  assured  that  the  cause 
of  offence  will  not  be  removed  until  she  endeavors  to 
control  herself. 

In  the  interval  between  the  paroxysms,  when  the 
patient  often  lies  in  an  apparently  unconscious  condition 
(though  almost  invariably  it  is  feigned,  and  can  be 
detected  by  a  close  observer),  she  is  placed  on  the  left 
side  in  Sims'  position,  and  the  asafoetida  and  hot  water 
given  very  slowly  as  an  enema.  The  object  of  this  is 
twofold.  It  serves  to  allay  reflex  irritation,  and  absorbs 
the  flatus  which  is  often  generated  in  large  quantities. 
It  is  necessary,  therefore,  to  give  a  large  enema,  and 
encourage  the  patient  to  retain  it  as  long  as  possible, 
aided  by  the  pressure  of  the  nurse's  hand  and  a  folded 


TREATMENT  OE  EPfLEPSV.  I4I 

napkin  against  the  anus.  The  bed-pan  should  receive 
the  evacuation,  as  the  exertion  of  getting  up  might 
cause  another  attack  in  spite  of  the  patient's  efforts  of 
self-control.  When  the  rectum  is  not  filled  with  faeces, 
the  insertion  of  a  long  rectal  tube  to  draw  off  the  flatus 
is  very  beneficial,  while  the  prolonged  sound  of  escaping 
flatus,  the  moment  the  abdominal  muscles  begin  to  con- 
tract preparatory  to  an  attack,  so  mortifies  a  sensitive 
patient,  that  she  will  exert  every  effort  to  lie  perfectly 
quiet  and  behave  herself. 

There  is  no  disease  which  depends  so  much  on  the 
tact  of  the  physician  for  its  successful  treatment,  as 
hysteria.  Before  he  tries  the  above-mentioned  meas- 
ures, he  should  endeavor  to  win  the  perfect  confidence 
of  his  patient ;  but  not  through  sympathy.  The  greater 
the  confidence  of  the  patient,  the  more  readily  can  she 
be  taught  to  exercise  her  will-power  and  self-control. 
Sometimes  her  surroundings  must  be  entirely  changed 
to  free  her  from  depressing  influences,  the  gossip  of 
neighbors,  etc.  ;  while  some  agreeable  occupation — the 
study  of  music,  painting,  or  the  languages  —  will  serve 
to  divert  her  attention  from  herself. 

Daily  salt-water  baths,  followed  by  vigorous  friction  of 
the  skin,  or  massage,  are  excellent  adjuvants.  In  long- 
standing cases  of  hysterical  paralysis  or  muscular  con- 
tractions, rest,  diet,  and  massage  should  be  thoroughly 
tried.  These  cases,  however,  are  not  peculiar  to  either 
puberty  or  the  climacteric,  and  will  not  be  considered 
here. 

In  the  Treatment  of  Epilepsy  during  an  attack,  there 
is  little  to  be  done,  except  to  prevent  any  injury.  A 
piece  of  soft  wood  or  cork  should  be  kept  between  the 
teeth  to  prevent  biting  the  tongue.  Menstrual  epilepsy, 
i.e.,  epilepsy  at  the  menstrual  periods,  which  is  the  only 
form  considered  here,  is  often   associated  with   hysteria, 


142     PUBERTY  AND    THE   CLIMACTERIC  PERIOD. 

and,  unless  it  disappears  soon  after  the  age  of  puberty, 
is  scarcely  ever  cured.  In  these  cases,  the  ovaries  have 
been  removed  with  varying  results.  Sometimes  per- 
manent cure  follows  the  operation,  but  not  so  uniformly 
that  any  absolute  promises  of  recovery  can  be  made. 
The  most  suitable  cases  for  this  treatment  are  those 
where  the  ovaries  are  enlarged  and  very  sensitive,  i.e., 
diseased,  and  where  the  patient  is  entirely  free  from 
epilepsy  between  the  monthly  periods.  This  also  applies 
to  menstrual  chorea  remaining  after  the  regular  appear- 
ance of  the  menses,  which  resists  all  other  treatment. 
The  remedies  for  chorea,  hysteria,  and  epilepsy,  over- 
lap each  other,  and  to  save  space  are  given  together.  It 
is  needless  to  remark  that  medicines  applicable  to  the 
treatment  of  chorea,  hysteria,  or  epilepsy,'  during  middle 
life  or  independent  of  the  menstrual  flow,  are  also  useful 
for  the  treatment  of  menstrual  epilepsy,  or  during  the 
age  of  puberty,  if  the  symptoms  show  a  proper  corre- 
spondence to  the  remedy.  The  references,  therefore, 
are  not  limited  to  the  menstrual  forms  occurring  at  the 
age  of  puberty,  or  at  the  climacteric. 

THERAPEUTICS    OF    CHOREA,    HYSTERIA,    AND    EPILEPSY. 

(Compare  classification  of  remedies  for  these  diseases, 
at  close  of  the  therapeutics.) 

Agaricus  has  been  useful  for  both  chorea  and  epilepsy. 
The  symptoms  indicate  its  use  in  the  former  rather  than  the 
latter  malady.  Involuntary  muscular  twitchings,  either  slight  or 
severe,  oi  the  face  (Cic,  belL,  ign.,  nux  worn.),  hands,  or  gluteal 
muscles  ;  sensitiveness  of  the  spine  (Cimicif., //z<?j'.),  especially  in 
the  lumbar  region ;  itching,  burning,  and  redness  of  the  toes, 
as  if  frost-bitten ;  tremor  of  the  hands  ;  involuntary  movements 
only  while  awake. 

'  There  is  an  exhaustive  and  able  article  on  the  HomcEopathic  Treatment  of 
Epilepsy,  by  Dr.  J.  Baertl,  in  the  Horn.  Vierteljarhschrift,  p.  234,  1S62.  Trans- 
lated in  the  British  Journal  of  Horn.,  vol.  xxii. 


THERAPEUTICS   OE  CHOREA,    ETC.  1 43 

I  Argentum  nitricum  has  proved  useful  for  epilepsy, 
though  the  precise  symptoms  calling  for  it  in  this  disease  are 
not  clearly  defined.  Dr,  Gray  of  New  York  asserted  that 
"  epilepsies  originating  in  the  brain  may  be  promptly  and 
durably  cured  by  a  few  small  doses,  while  those  proceeding 
from  abdominal  irritation  can  be  barely  palliated  by  large  quan- 
tities." Epilepsy  from  fright  (Gels.,  opium,  stram.),  during  the 
menses  (Cimicif.),  pupils  dilated  a  day  or  two  before  the  parox- 
ysm ;  periodical  trembling  of  the  body  ;  chorea-like,  convulsive 
motions  of  the  limbs  f  great  forgetfulness. 

Arsenicum.  Dr.  Hughes  styles  it  the  prince  of  remedies 
in  chorea  and  neuralgia.  Trembling  and  weariness  of  the 
limbs  ;  uneasiness  of  lower  limbs,  cannot  lie  still  at  night;  pal- 
pitation, especially  at  night ;  burning  sensations,  internally  or 
externally ;  sensation  of  warm  air  streaming  up  into  the  head, 
preceding  the  epileptic  attacks  ;  frequent  starting  in  and  from 
sleep  ;  great  weakness  and  prostration. 

Belladonna.  Sulphate  of  atropia  is  preferred  by  many 
physicians.  Menstrual  epilepsy,  from  sudden  suppression  of 
the  flow  (Gels.,  glon.,  veratrum  vir.),  or  with  scanty  menstrua- 
tion. Intense  cerebral  congestion  ;  face  glowing  red,  hot,  and 
swollen  ;  convulsive  movements  of  the  muscles  of  the  face  and 
mouth.  The  right  hand  clutches  at  the  throat ;  intense  head- 
ache, then  epilepsy ;  finally,  menstrual  flow.  In  two  cases  '  of 
this  kind,  reported  cured  by  atropia  sulph.,  there  was  a  great 
deal  of  pain  in  the  left  ovarian  region. 

Bromide  of  Potash  has  held  high  rank  in  the  treatment 
of  epflepsy,  but  is  not  likely  to  be  required  for  the  cases  con- 
sidered here.  It  is  a  palliative  in  large  doses  only,  and  rarely, 
if  ever,  cures  the  patient  j  while  the  after-effects  of  the  drug, 
impairing  the  intellect,  and  producing  the  well-known  acne,  if 
pushed  to  excess,  seem  to  counterbalance  the  benefit  derived 
from  palliation.  Unless  hfe  or  reason  be  endangered,  the 
faithful  trial  of  a  carefully  selected  remedy,  which  does  not 
cause  such  disastrous  after-effects,  is  recommended. 

^  Raue,  Record  of  Horn.  Literature,  p.  252,  1S75. 


144    PUBERTY  A  AW    THE   CLIMACTERIC  PERIOD. 

Calcarea  Ars.  Dr.  C.  Hering  '  wrote  of  this  in  1849: 
"  From  no  remedy  liave  I  obtained  such  good  results,  in  cases 
of  epilepsy."  It  has  not  been  proved,  but  is  probably  very 
similar  to  calcarea  carb.,  which  has  some  reputation  in  epilepsy.^ 
Dr.  S.  Worcester  states  that  he  has  found  it  very  valuable  in 
young  children.  The  constitutional  symptoms  are  of  prime 
importance,  such  as  a  scrofulous  diathesis,  tendency  to  obesity, 
profuse  perspiration,  with  feeling  of  weariness  and  prostration. 
To  these  may  be  added  :  the  sensation,  before  the  attack,  of 
something  running  in  the  arm,  or  from  pit  of  stomach  down 
through  abdomen  into  the  feet ;  great  anxiety,  and  palpitation 
of  the  heart ;  frightened,  apprehensive  mood,  and  forgetfulness. 

Caulophyllum.  Chorea  at  puberty.  Hysterical  or  epilep- 
tiform spasms  at  puberty,  from  menstrual  irregularities,  espe- 
cially in  persons  subject  to  rheumatism  of  the  small  joints,  as 
the  wrists  and  fingers. 

Causticum.  Dr.  Jahr  praises  it  for  mild  cases  of  chorea. 
If  ignatia  fails  in  the  treatment  of  minor  cases  of  chorea,  caused 
by  sudden  fright,  he  gives  causticum.  Dr.  GouUon  ^  reports  a 
long-standing  case  of  epilepsy  cured  by  this  remedy,  in  the 
third  dilution.  Epileptic  attacks,  during  the  time  of  puberty, 
with  delay  of  the  first  menses ;  also  worse  during  the  new 
moon.     (Silicea.) 

Cicuta  vir.  Though  the  symptoms  of  this  drug  resemble 
an  epileptic  attack,  it  only  seems  to  have  a  palliative  effect. 
The  menses  are  delayed,  and  there  is  a  spasmodic  state  if  they 
do  not  appear.  The  larger  muscles  of  the  limb  and  trunk 
seem  to  be  most  involved ;  convulsions,  with  loss  of  conscious- 
ness, with  opisthotonos ;  paroxysms,  with  swelling  of  the 
stomach,  as  from  violent  spasms  of  the  diaphragm  ;  hiccough, 
screaming,  red  face,  trismus,  loss  of  consciousness,  and  distor- 
tion of  the  limbs  ;  pupils  dilated  and  insensible. 

I  Cimicifuga.  Menses  irregular,  delayed,  or  suppressed; 
hysterical  or  epileptic  spasms  at  the  time  of  the  menses,  espe- 

'  Brit.  Journal  of  Horn.,  vol.  vii.  p.  564. 

^  Ibid.,  vol.  xxii.  pp.  246,  24S. 

^  Case  in  Hoyne's  Clinical  Therapeutics,  vol.  i.  p.  386. 

3  Allgemeine  Horn.  Zeitung,  vol.  69. 


THERAPEUTICS   O l<    CHOREA,   ETC.  1 45 

cially  in  rheumatic  subjects  ;  nervous  shuddering ;  tremor  all 
over  the  body. 

Cocculus  ind.  This  promises  to  become  a  good  remedy 
for  epilepsy  '  as  well  as  hysteria.  Cures  of  the  former  by  it  in 
the  form  of  a  strong  tincture,  have  been  obtained  by  M.  Felix 
Planat.^  The  patient  is  most  subject  to  attacks  at  the  time 
of  the  menses.  The  flow  is  scanty  and  painful;  menstrual 
headache,  with  vertigo,  nausea,  and  accumulation  of  flatus, 
especially  at  night ;  involuntary  motions  of  right  arm  and  leg, 
which  cease  during  sleep.  Dr.  Jousset  ^  found  that  both  coco, 
ind.  and  picrotoxine  caused  epilepsy,  and  thinks  he  obtained 
good  results  from  it. 

Cuprum.  Drs.  Bayes,  Bahr,  Jahr,  and  Jousset  consider  it 
an  excellent  medicine  in  epilepsy ;  and  Dr.  Baertl  mentions 
cases  cured  by  it.  The  convulsions  are  extremely  violent. 
Dr.  Hughes  commends  it  for  the  final  steadying  of  the  muscles 
in  chorea,  after  the  use  of  cimicifuga,  agaricus,  or  stramonium  ; 
and  adds  as  a  characteristic  of  cuprum  in  nervous  disorders, 
that  they  begin  with  cramps  in  the  extremities,  especially  in  the 
fingers  and  toes  ;  spasmodic  dyspnoea  before  the  menses. 

Hydrocyanic  acid.  Dr.  Hughes  ^  recommends  this  drug, 
on  account  of  the  very  great  similarity  of  the  symptoms  to  epi- 
lepsy, and  states  that  it  is  his  practice  to  give  from  five  drops  of 
the  third  decimal  attenuation  to  three  drops  of  the  second  deci- 
mal three  times  a  day.  He  has  also  found  it  useful  for  the  vertigo 
of  epileptics,  when  not  amounting  to  the  '^ petit  viaiy  Dr.  S. 
Worcester  states  that  his  experience  with  the  remedy  has  not 
been  satisfactory,  but  does  not  say  whether  he  employed  the 
drug  in  a  high  or  low  potency.  It  appears  to  be  chiefly  appli- 
cable to  acute  cases. 5 

'  Experiments  with  picrotoxine,  the  active  principle  of  cocculus  indicus,  show 
that  it  will  produce  genuine  epilepsy.  — Lo7idon  Med.  Record.,  May  15,  1883. 

2  Hughes'  Pharmacodynamics,  p.  420,  1886. 

3  Monthly  Horn.  Review,  p.  104,  Feb.  i,  1S81. 

■*  Transac.  World's  Hom.  Convention,  vol.  i.  p.  177,  1876. 

5  In  an  excellent  lecture  on  epilepsy,  Dr.  J.  Rutherford  Russel  does  not  speak 
favorably  of  hydrocyanic  acid,  and  mentions  the  following  remedies :  Bell.,  cupr., 
ars.,  naja,  lach.,  (nit.  silver),  nux  vom.,  pulsatilla.  —  Annals  Brit.  Horn.  Soc, 
p.  258,  vol.  iii. 


146    PUBERTY  AND    THE   CLIMACTERIC  PERIOD. 

Hyoscyamus.  Menses  preceded  by  hysterical  or  epileptic 
spasms  ;  laughing  loud,  uninterrupted  ;  profuse  sweat  and 
nausea.  During  the  menses,  convulsive  trembling  of  the  hands 
and  feet ;  headache  ;  profuse  perspiration,  and  nausea ;  pale 
flow,  with  convulsions:  lascivious  mania.  Drinking  is  liable  to 
renew  the  paroxysms. 

Ignatia.  Recent  cases  of  hysteria,  chorea,  or  epilepsy,  due 
to  mental  emotions,  without  hereditary  disposition. 

Moschus.  Dr.  Hughes  writes  :  "  I  know  nothing  which  so 
rapidly  dissipates  an  hysterical  attack,  even  when  it  has  gone 
so  far  as  unconsciousness,  as  moschus.  It  is  equally  potent 
for  palpitation  caused  by  nervous  excitement,  without  organic 
disease  of  the  heart.  It  needs  to  be  used  in  about  the  third 
decimal  trituration." 

Oenanthe    croc'      Dr.  S.  Worcester  writes  favorably  of 

^  Girl,  aet.  16.  At  nine  years  of  age  she  was  seized  with  spasmodic  jerkings, 
salivation,  and  with  absohite  unconsciousness  during  the  spasms.  For  a  year  they 
were  controlled  by  bromide  of  potash,  and  did  not  return  till  she  was  nearly  twelve 
years  old,  when  she  had  a  number  of  attacks  at  night,  and  the  menses  appeared  on 
the  following  day.  From  this  time,  she  had  frequent  attacks  during  the  day,  and 
nearly  every  night  a  number  during  sound  slumber.  The  menses  were  very  irregular, 
sometimes  skipping  a  number  of  months.  The  patient  became  debilitated,  jaun- 
diced, and  had  an  imbecile  expression  ;  appetite  capricious.  The  attack  ceased 
on  taking  oenanth.  croc.  ;  the  appetite  became  good ;  menses  regular,  and  every 
appearance  of  health  restored.  The  remedy  was  continued  for  six  weeks.  —  Dr. 
W.  A.  Dunn,  U.  S.  Investigator,  p.  238,  .Sept.  i,  1882. 

Girl,  set.  14.  She  had  been  sick  two  years,  and  treated,  without  any  improve- 
ment, by  large  doses  of  potassium  bromide,  etc.  She  came  under  my  care  April  6, 
1884.  Her  attacks  were  epileptic  in  character;  began  with  a  cry;  she  then  fell 
and  became  unconscious  ;  had  clonic  spasms  in  the  limbs,  with  frothing  at  the 
mouth,  and  rolling  of  the  eyeballs  ;  the  hands  were  clinched  with  the  thumbs  inside. 
During  the  attack,  rectum  and  bladder  were  sometimes  emptied.  The  attacks 
came  three  or  four  times  a  week,  or  it  might  be  only  every  two  weeks.  After  the 
attack  she  slept  five  or  six  hours,  and  then  complained  of  heaviness  in  the  head, 
and  feeling  of  exhaustion,  as  if  she  had  been  beaten  ;  the  memory  was  somewhat 
imparled.  During  the  attacks  she  was  now  red,  now  pale,  in  the  face.  She  was 
well  developed,  but  had  not  had  her  menses.  Cupr.  met.  24X.,  bell.  6x.,  ignatia  6x., 
and  puis.  30,  were  given  with  little  benefit.  The  attacks  became  a  little  less 
frequent,  but  still  were  quite  violent.  On  Nov.  2  the  spcam  was  violent  in  the  face, 
and  during  it  the  face  was  of  a  leaden-gray  color,  and  appeared  swollen. 
Oenanthe  croc.  6x.  was  prescribed,  three  drops  morning  and  evening,  for  nine  da)  s  ; 
then  to  wait  four  days,  begin  again,  etc.  Until  Dec.  7,  there  was  no  attack.  In 
January  and  February,  18S5,  there  were  two  insignificant  attacks  each  month. 


TREATMENT  OF  CHOREA,    HYSTERIA,   ETC.     F47 

this  drug  for  epileptic  convulsions.  The  pupils  are  dilated  ; 
the  face  livid  and  turgid,  and  rapid  convulsive  twitchings  of  the 
facial  muscles.  All  the  symptoms  are  worse  from  water. 
(Compare  cases  and  references  below.) 

Platina.  Spasmodic  affections  of  hysterical  women  sub- 
ject to  melancholia  ;  spasms  from  sexual  erethism ;  nymphoma- 
nia ;  menses  too  profuse. 

Plumbum."  Drs.  Hughes  and  Bahr  rank  plunibum  with 
cuprum  as  one  of  the  remedies  from  which  the  most  can  be 
expected  in  chronic  cases  of  epilepsy.  A  cure  of  one  case, 
which  had  lasted  thirteen  years,  has  been  recorded,^  and  also 
a  second,^  successfully  treated  by  this  remedy. 

Pulsatilla.  First  menses  delayed  or  scanty ;  hysteria,  with 
constantly  changing  symptoms  ;  patient  complains  of  constant 
chiUiness,  or  dry  burning  heat,  and  feels  better  in  the  open  air. 
Where  there  is  a  decided  anaemic  condition,  pulsatilla  is  not  so 
useful  as  where  the  system  is  well  nourished,  and  can  afford  the 
loss  of  menstrual  blood.  In  the  latter  case,  the  remedy  is  of 
great  benefit  as  a  stimulant  to  the  menstrual  flow,  and  to  pro- 
mote the  establishment  of  the  menses  at  regular  intervals.  The 
writer's  experience  has  been,  that  if  the  third  decimal  dilution 
fails  to  produce  the  desired  effect,  lower  dilutions  or  the  tinc- 
ture will  also  fail. 

Stramonium.  Nymphomania  ;  metrorrhagia  ;  loquacity, 
singing  and  praying  ;  hysteria,  preceded  by  great  sensitiveness  ; 
sexual  excitement ;  chorea  or  epilepsy  from  fright ;  trembling 

In  April,  May,  and  June,  an  attack  each ;  and  later  she  was  quite  well.  Memory 
is  good;  all  the  functions  are  normal;  the  color  of  the  face  is  good ;  and,  when  I 
saw  the  girl  in  1S86,  she  stated  that  the  first  menstruation  occurred  fourteen  days 
before,  and  that  she  was  quite  well.  She  used  osnantha  croc,  until  August,  1S85  ; 
and  then  I  gave  her,  as  a  final  prescription,  sulphur  30,  three  drops  morning  and 
evening.  —  Dr.  Oscar  Hansen,  Allg.  Horn.  Zeitung,  vol.  113,  Nos.  2-6,  18S6. 
Translat.  in  Horn.  Recorder,  p.  168,  November,  1886. 

For  further  information,  the  reader  is  referred  to  the  Horn.  Recorder,  Sept.  15, 
1886;  the  British  Joiir^ial  of  Ho7tt.,  p.  459,  July,  1874;  Dublin  Med.  youriial; 
and  Hale''s  Therap.,  p.  505,  i88o,  — where  a  good  description  of  the  post-mortem 
appearances,  caused  by  this  powerful  poison,  can  be  found. 

'  A  case  of  epilepsy,  from  lead-poisoning,  is  reported  in  the  New-England 
Med.  Gazette,  p.  166,  1S67. 

^  Monthly  Horn.  Review,  vol.  xiii.  p.  574.  ^  Ibid.,  May,  iS;8. 


148    PUBERTY  AND    THE   CLIMACTERIC  PERIOD. 

of  the  limbs  ;  twitching  of  the  hands  and  feet,  or  of  the  tendons  \ 
catalepsy  (Cannabis  indica)  ;  convulsions,  aggravated  by  water 
(Hyosc,  oenanthe). 

Veratrum  Viride.  An  exceedingly  useful  remedy  for 
acute  suppression  of  the  menses,  in  plethoric  women,  with 
intense  cerebral  congestion  (Aeon.,  bell.,  gels.,  glon.).  The 
arterial  excitement  is  great ;  twitchings  and  contortions  of  the 
body ;  opisthotonos.  Dr.  Cooper '  has  found  it  useful  for 
chorea. 

The  following  remedies /or  the  diseases  under  consid- 
eration have  been  recommended  by  various  physicians  :  — 

Epilepsy. — Arg.  nit.,  alumina,  ars.,  artemisia,^  bell., 
bufo.,3  calc.  ars.,  calc.  card.,  caustictmi,  cicut.  vir.,  cinch.,"* 
cocc.,  colocynth,  citpr.,  hydrocyanic  acid,  ignatia,  kali 
brom.,  lach.,  HI.  tig.,  lye,  nit.  ac,  cenanthe  croc.,^  opium, 
plumb.,  phos.  ac,  secale  cor.,  silicea,^  stram.,  strychnia,^ 
(nux  vom.),  sulph. 

Hysteria.  — Asaf.,  aurum,  bovista,^  cimicif.,  cocc,  coni., 

'  Brit.  Journal  of  Horn.,  vol.  xxxiv.  p.  272. 

2  Nothnagel,  Ziemssen's  Cyclopsedia,  vol.  xiv.  p.  2S8, 

3  Raue,  Record  of  Horn.  Literature,  p.  226,  1872. 

+  Cinchonidin  will  produce  true  epilepsy.  —  London  Med.  Record,  May  15, 
1883. 

s  Girl,  set.  14 ;  had  epileptic  spasms  for  the  last  three  years  when  going  to 
bed,  and  sometimes  after  she  was  in  bed.  Spasms  generally  lasted  from  half  an 
hour  to  an  hour  and  a  half,  and  were  both  preceded  and  followed  by  unusual  faint- 
ness.  In  the  daytime  she  was  frequently  attacked  with  vertigo.  The  fits  were 
suppressed  whenever  the  patient  rode  in  a  carriage,  and  this  suppression  was  pro- 
portionate to  the  lengtli  of  the  ride.  Nit.  ac.  4X.,  two  doses  a  day,  cured  her. — 
Hoyne's  Clinical  Therapeutics,  vol.  i.  p.  452. 

*  C.  Dunham,  Transactions  N.  Y.  State  Horn.  Soc  ,  1871 ;  also  Lectures  on 
the  Mat.  Med.,  vol.  i.  p.  335. 

7  Hughes'  Pharmacodynamics,  1886,  p.  694. 

8  Girl,  ffit.  21,  pale,  cachectic;  has  had  spasms  for  a  long  time,  which  occur 
before  the  menses  or  after  mental  emotion,  and  are  preceded  by  tearing  and  stitch- 
ing from  the  left  shoulder  to  the  elbow.  They  are  especially  violent  at  night,  and 
when  at  rest  Spasms  sometimes  twice  a  day.  She  is  seized  first  with  constant 
yawning,  followed  by  stitches  in  the  throat,  sensation  as  if  the  tongue  were  cut 
through  with  a  knife,  accompanied  with  painful  tensions  in  the  mouth,  and  con- 
vulsions of  all  the  facial  muscles,  after  which  spasmodic  weeping  and  laughter  with 


NYMPHOMANIA.  — MENSTRUAL  HEADACHES.     1 49 

graph.,  hyosc,  ignatia,  mag.  mur.,  moschus,  mix  mosch., 
plat.,  puis.,  tarreiitula,  theridion,  sepia,  valerian,  zincum 
val. 

Chorea.  —  Agaricus,  ars.,  calc.  carb.,  caust.,  cimicif., 
cocc,  ciipr.,  hyosc ,  ignatia,  naja,  phos.  ac.,'  stram., 
sulph.,  tarrentula,  vei^atr.  vir.,  zincum,  zizia  aur.^ 

Nymphomania  is  fortunately  not  a  common  complaint, 
and  is  mentioned  here  as  one  of  the  neuroses.  A  person 
suffering  from  this  trouble  is  to  be  pitied,  and  not 
considered  at  all  responsible  for  her  words  or  actions. 
The  following  remedies  are  the  most  useful  for  this 
affection  :  agaricus,  arsenicum,  canth.,  china,  grat., 
hyosc,  lach.,  HI.  tig.,  lycopod.,  origanum,  picric  acid, 
phos.,  platina,  sabina,  stramonium,  veratr.  alb.,  zinc. 

In  a  limited  number  of  cases,  which  might  be  termed 
emissions  in  women,  i.e.,  orgasm  and  discharge  of  fluid, 
platinum  has  proved  the  best  remedy  in  my  practice. 

The  Headaches  ^  which  sometimes  attend  the  men- 
strual period  are  very  distressing,  but  fortunately  are 
usually  curable  if  they  are  not  hereditary  and  the  causes 
can  be  removed.  Prominent  among  the  latter  are 
plethora,  ovaritis,  and  uterine  displacement,  besides 
the  usual  causes  of  headache  when  it  is  independent 
of  the  monthly  flow.  Too  much  stress  cannot  be  laid 
on  the  importance  of  removing  any  abnormal  condition 
of  the  sexual  organs  before  a  cure  can  be  promised. 

• 

suffocation,  constriction,  or  distension  of  the  throat ;  and,  lastly,  with  spasms  of 
tlie  chest,  and  dark  red  face.  Bovista  18  cured  her. —  Hoyne's  Cli7i.  Therap., 
vol.  ii.  p.  488. 

'  A  very  interesting  case,  cured  by  phos.  ac,  is  reported  by  Hempel  in  Baehr's 
Therapeutics,  vol.  i.  p.  176. 

2  Hale,  New  Remedies,  2d  ed.,  p.  1079. 

3  The  reader  is  referred  to  a  very  interesting  and  carefully  written  article  on 
the  Treatment  of  Headaches,  by  Francis  Black,  M.D.,  in  the  British  Journ.  of 
Horn.,  vol,  v.  p.  325  ;  also  vol.  xxii.  by  the  same  author ;  and  Headache  or  Migraine, 
by  Dr.  Trinks,  Horn.  Vierteljahrschrift,  vol.  iv.  p.  100,  translated  in  the  British 
Journal  of  Horn.,  pp.  i  and  276,  1863,  vol.  xxi. 


ISO    PUBERTY  AND    THE   CLIMACTERIC  PERIOD. 

The  headaches  are  of  various  types,  and  the  same 
remedies  for  the  more  common  forms  of  headache  are 
applicable  here  according  to  the  symptoms.  Not  only 
is  it  necessary  to  repeat  the  medicine  at  short  intervals 
during  the  attack  till  there  is  improvement,  but  also  to 
give  it  at  intervals  afterwards,  to  avoid  or  break  up  the 
tendency  to  recurrence  of  the  paroxysms.  In  obstinate 
cases,  some  constitutional  remedy  such  as  baryta  carb., 
calc.  carb,  graph.,  natrum  mur.,  sepia,  silicea,  or  sulphur, 
must  be  carefully  selected,  and  used  persistently  for 
months  if  necessary,  before  the  patient  can  be  cured. 

THERAPEUTICS. 

Belladonna.  Severe  throbbing,  pulsating  headache  before 
or  during  the  menses ;  also,  if  this  severe  throbbing  or  stabbing 
pain  follows  a  sudden  suppression  of  the  flow  in  plethoric  sub- 
jects. The  face  is  red  and  hot,  and  not  infrequently  there  is 
much  weight  or  bearing-down  in  the  pelvis. 

Cactus  has  been  commended  for  pressive  headache  in  the 
vertex,  resulting  from  menorrhagia,  also  for  a  similar  headache 
at  the  menopause. 

Cimicifuga.  ytx'i\go,  fulness  and  dull  aching  in  the  ver- 
tex ;  dull  aching,  especially  in  the  occiput,  with  sense  of  sore- 
ness in  that  region ;  intense  aching,  sore  pain  in  the  eyeballs  ; 
headache  worse  during  the  menses  from  motion  and  indoors, 
belter  in  the  open  air ;  shooting  pains  in  the  ovaries,  tenderness 
over  the  uterus,  and  irregular,  delayed,  or  suppressed  menses. 

Cocculus  is  highly  esteemed  for  menstrual  headache  in 
hysterical  women,  when  the  head  feels  empty  and  hollow,  and 
there  is  inclination  to  vomit  with  much  nausea,  especially  when 
rising  up,  and  with  flatulent  distension  of  the  abdomen  ;  much 
confusion  in  the  head. 

Cuprum.  Spasmodic  dyspnoea  before  the  menses;  also 
rush  of  blood  to  the  head,  intense  pain  extending  from  the 
neck  into  the  occiput ;  cramps  in  the  abdomen  with  nausea 
and  vomiting ;  headache  begins  twelve  to  twenty-four  hours 
before  the  flow,  and  is  better  when  the  latter  is  established. 


THERAPEUTICS  OF  MENSTRUAL  HEADACHE.     151 

Gelsemium.  The  writer  has  had  prompt  results  from  the 
IX.  or  2x.  where  it  failed  in  higher  potencies.  If  good  is  to 
follow,  relief  is  experienced  after  two  or  three  doses.  As  a  rule, 
it  needs  to  be  re-enforced  by  some  constitutional  remedy  given 
in  the  intervals  between  the  monthlies.  Before  or  with  sup- 
pressed menses,  congestion  of  blood  to  the  head  ;  severe  pain 
in  the  head  and  face,  of  a  neuralgic  or  spasmodic  type,  vertigo, 
blurred  vision  (Iris),  nausea  and  vomiting  ;  profuse  emission  of 
clear  urine,  which  relieves  the  headache  ;  sometimes  a  feeling 
of  stupor  or  drowsiness  ;  less  frequently  chilliness  precedes  the ' 
headache,  which  is  worse  from  lying  down. 

I  Glonoine.  The  chief  remedy  for  sudden  suppression  of 
the  menses  in  plethoric  women,  or  with  scanty  menses,  accom- 
panied by  intense  cerebral  congestion  ;  violent  throbbing  head- 
ache increased  by  every  motion ;  head  feels  full,  face  red, 
pulse  full  and  quick ;  throbbing  from  neck  extending  into 
occipital  region.  (The  congestion  of  aeon.,  bell.,  and  gels.,  is 
not  so  intense  as  glonoine  ;  but  the  actual  pain  is  more  severe, 
and  the  symptoms  of  fever  and  inflammation  are  much  more 
prominent.) 

Graphites.  A  good  constitutional  remedy  ;  menses  scanty 
or  delayed ;  flow  often  pale;  swelling  and  induration  of  the 
ovaries  without  much  local  inflammation ;  violent  headache 
with  eructations  and  nausea  during  the  menses,  or  tearing  pain 
in  the  epigastrium  at  this  time.  Constipation,  stool  dark,  large 
and  knotty,  half- digested,  and  offensive  ;  skin  eruptions  exuding 
a  watery,  sticky  fluid. 

Ignatia  '  Severe  pressing  headache  during  menstruation, 
with  frequent  spasmodic  yawning,  and  emission  of  watery  urine 
every  few  minutes.  It  is  best  adapted  to  nervous,  hysterical 
women. 

Natrum  mur.  Headache  before,  during,  or  after  the 
menses,  with  depression  of  spirits ;  heavy  pressive  pain  in  the 
forehead  over  both  eyes  ;  severe  bursting  headache,  also  dull, 
pressive,  stupefying  headache  \   headache  in  schoolgirls  (Phos. 

'  The   Ignatia    Headache:    Dr.  Shuldham,   Monthly   Homosopathic   Review, 

vol.   XV. 


152    PUBERTY  AND    THE   CLIMACTERIC  PERIOD. 

ac),  especially  in  the  morning.  The  characteristic  constipation, 
emaciation,  and  sense  of  prostration,  as  well  as  the  presence 
of  itching  eruptions  on  the  skin,  are  additional  indications  for 
this  remedy. 

Pulsatilla.  Dull,  pressive  headache,  with  bruised  sensa- 
tion in  the  forehead,  at  the  age  of  puberty  before  the  first 
menses  have  appeared,  or  when  the  flow  is  delayed  and  scanty. 
The  patient  is  depressed  mentally,  and  complains  of  chilUness 
in  the  daytime,  and  dry,  burning  heat  without  thirst  at  night. 
"T"he  headache  is  relieved  by  pressure,  and  by  walking  slowly  in 
the  open  air. 

Sanguinaria.  Menses  at  the  right  time,  with  scanty  flow, 
and  severe  throbbing  headache,  extending  from  the  occiput 
over  the  head  to  the  frontal  region,  especially  the  right  side ; 
vertigo ;  face  red  and  hot,  less  often  pale,  with  disposition  to 
vomit ;  eruption  on  the  face  of  young  women  with  menstrual 
troubles,  and  especially  a  scanty  flow. 

I  Sepia.  One  of  the  best  remedies  for  the  radical  treatment 
of  obstinate  cases  with  the  following  indications  :  heavy  pressive 
pain  in  the  left  orbit  and  left  side  of  the  head,  with  darting 
pains  over  the  left  side  of  the  head,  better  after  eating ;  morn- 
ing nausea ;  sinking,  "  gone  "  sensation  in  the  stomach;  bear- 
ing-down in  the  pelvic  organs ;  menses  irregular  or  scanty ; 
sexual  instinct  increased ;  foetid  perspiration  about  genitals, 
axilla  and  soles  of  feet ;  moth  spots  or  yellowish  discoloration 
of  the  skin  ;  itching,  herpetic  eruptions.  The  constitutional 
symptoms  are  more  important  than  those  relating  solely  to  the 
headache. 

The  following  remedies  are  also  useful :  — 
Apis  (headache  M^ith  right-sided  ovarian  irritation), 
^aryta  carb.,  calc.  carb.,  cannabis  sat.,  cham.,  cyclamen, 
iris  vers,  (sick  headache  preceded  by  a  blur  before  the 
eyes),  lachesis  (headache  with  left-sided  ovarian  irrita- 
tion), naja,  natrum  carb.,  mix  vom.,  platina,  senecio, 
silicea,  sulphur. 

Toothache  is  sometimes  a  distressing  complication  of 


TOOTHACHE  AT  MENSTRUAL  PERIODS.      I  53 

menstruation.  Dr.  Hering  recommends  the  following 
remedies,  to  which  a  few  mentioned  by  Dr.  Baehr,  but 
not  by  the  former  physician,  are  added.  The  latter  are 
marked  by  a  star,  and  are  not  to  be  considered  any  more 
characteristic  than  the  other  remedies. 

Toothache  before  Menstruation. — Arsetiicmn,  *  aeon., 
*  bell.,  *cham.,  *  puis. 

Toothache  during  Menstruatio7t. — -Calc.  carb.,  chain., 
carbo  veg.,  lachesis,  natr.  mur.,  *  sepia,  phosphorus. 

Toothache  after  MenstriMtion.  —  Bryonia,  calc.  carb., 
cham.,  phos. 

Aphonia  or  weakness  of  voice,  coming  on  at  each 
menstrual  period,  has  been  cured  by  gelsemium.'  Dr. 
Richard  Hughes  mentions  antimonium  crudum  when  it 
occurs  every  time  the  patient  is  exposed  to  heat. 

The  Anomalies  of  the  Climacteric  Period  (menopause) 
may  be  considered  as  those  of  perverted  nutrition,  such 
as  the  development  of  obesity,  benign  or  malignant 
growths,  and  disturbances  of  the  vaso-motor  system  caus- 
ing flushings,  local  congestion,  etc.  Hysteria  sometimes 
appears,  and  there  is  marked  irregularity  of  the  menses 
both  in  time,  character,  and  duration  of  the  flow.  The 
growth  of  neoplasms,  as  well  as  the  derangement  of  the 
menses,  have  already  been  mentioned  in  treating  of 
the  various  forms,  and  need  not  be  repeated  here.  The 
hygiene  has  been  described  in  the  beginning  of  this 
chapter,  so  there  only  remain  for  consideration  those 
remedies  peculiarly  applicable  to  vaso-motor  disturb- 
ances, which  play  such  an  important  part  in  the  suffer- 
ings of  the  climacteric  period. 

When  the  monthly  congestion  of  the  pelvic  organs 
and  the  flowing  have  permanently  ceased,  atrophy  of 
these  structures  gradually  progresses  from  year  to  year. 

'  Meyhoffer,  Chronic  Diseases  of  the  Organs  of  Respiration,  p.  230. 


154    PUBERTY  AND   THE    CLIMACTERIC  PERIOD. 

Consequently,  inflammatory  diseases  common  to  the 
menstrual  or  child-bearing  age  are  very  rarely  if  ever 
seen  in  the  post-climacteric  period.  Uterine  fibroids, 
which  may  have  developed,  scarcely  ever  increase  after 
the  flow  permanently  ceases,  and,  as  a  rule,  slowly  de- 
crease or  even  disappear.  The  suffering  incident  to 
uterine  displacement  is  much  relieved  ;  chronic  metritis 
and  ovaritis  gradually  undergo  spontaneous  cure.  Pro- 
cidentia, especially  if  complete,  seems  to  be  an  exception 
to  the  rule,  and  is  very  seldom  benefited  by  the  "change 
of  life." 

THERAPEUTICS.' 

Aconite  is  more  often  indicated  in  the  commencement  of 
the  climacteric  in  robust,  plethoric  women,  where  there  is  arte- 
rial tension  ;  pulse  quick,  full,  hard,  and  strong  ;  patient  is  timid, 
anxious,  restless,  complains  of  vertigo,  fulness  and  heavy  feel- 
ing in  the  forehead,  sometimes  epistaxis  of  bright  red  blood, 
and  the  senses  of  smell  arid  hearing  are  morbidly  acute.  Drs. 
Hughes  and  Leadam  urge  the  employment  of  only  the  medium 
or  higher  dilutions,  on  account  of  the  great  liability  to  produce 
aggravations  with  the  low  attenuations. 

Amyl  nitrite.  Flushings  of  the  climacteric  when  lachesis 
fails ;  heat  and  throbbing,  with  sensation  of  intense  fulness  in 
the  head ;  much  throbbing  in  the  ears ;  flushing  of  the  face ; 
choking,  constricted  feeling  about  the  throat. 

Argentum  nit.  Dr.  C.  Hering  marks  the  following  symp- 
tom :  metrorrhagia,  with  nervous  erethism  at  change  of  life, 
also  in  young  widows,  and  those  who  have  borne  no  children ; 
returns  in  attacks  ;  region  of  ovaries  painful,  with  pains  radiating 
to  the  sacrum  and  thighs ;  memory  impaired ;  vertigo  and 
buzzing  in  the  ears,  and  general  debility  of  the  limbs,  and  trem- 
bling ;  boring  pain  in  left  frontal  eminence,  or  dull  pressive 
pain  on  the  vertex,  relieved  by  binding  something  tightly  on  the 
head  (Silicea). 

'  Dr.  Richard  Hughes  has  an  excellent  article.  On  some  Remedies  for  Climac- 
teric Sufferings,  in  the  Biit.  Journ.  of  Hom.,  vol.  xxiv.  p.  619,  i866. 


THERAPEUTICS  OF  THE   CLIMACTERIC.      155 

Cactus.  Pressive,  burning  weight  on  the  vertex  (when 
from  loss  of  fluids,  china  and  ferrum)  if  lachesis  fails ;  sense  of 
oppression  or  constriction  of  the  chest  or  heart,  palpitation 
of  the  latter. 

Caulophyllin  3X.  Dr.  Ludlam  states  that  he  has  often  pre- 
scribed this  remedy  for  post-climacteric  nervous  conditions,  with 
excellent  results  ;  attacks  of  "  great  nervous  tension  and  unrest, 
with  wakefulness,  and  a  propensity  to  work  and  worry  over  little 
things."  The  presence  of  rheumatism  of  the  smaller  joints 
would  be  an  additional  indication  for  it. 

Cimicifuga  2x.  Restless  and  unhappy  state  of  mind ; 
the  patient  feels  grieved  and  troubled,  with  sighing  (Ignatia),  is 
irritable,  cannot  sleep ;  vertigo ;  fulness  and  dull  aching  in  the 
vertex;  sinking  at  the  stomach  (Hydrocyanic  ac). 

Coffea.  All  the  senses  are  very  acute  ;  patient  cannot  bear 
pain  ;  mind  very  active,  cannot  sleep  nights  on  account  of 
thinking,  hears  the  least  sound  ;  a  general  condition  of  marked 
nervous  excitement. 

Gelsemium  ix.  or  2x.  is  an  excellent  remedy  for  the  con- 
gestive headaches  of  the  chmacteric.  The  attack  often  begins 
with  drowsiness,  or  perhaps  chilliness,  then  severe  pain,  usually 
of  a  neuralgic  or  spasmodic  form,  sometimes  pulsation  of  the 
carotids,  and  accompanied  by  vertigo,  blurred  (Iris)  or  double 
vision,  occasionally  by  nausea  and  vomiting,  and  is  relieved  by 
the  profuse  emission  of  watery  urine. 

Glonoine  has  been  warmly  praised  for  congestions  of  the 
head,  and  flushings  limited  to  the  face,  also  for  its  characteristic 
headache ;  violent  throbbing  in  the  head,  or  from  neck  into  the 
occipital  region  \  head  feels  full,  face  red,  and  the  pulse  is  full 
and  quick. 

Helonine.  An  excellent  uterine  tonic;  profound  melan- 
choly, with  sensation  of  weight  and  soreness  in  the  uterus ; 
dragging,  aching,  and  weakness  in  the  sacral  region,  with  marked 
debility. 

Jaborandi  ix.  Dr.  Hughes  mentions  this  remedy  for 
flushings  at  the  climacteric  accompanied  with  sweating. 

II  Lachesis.    The  chief  remedy  for  flushings  at  the  climac- 


156    PUBERTY  AND   THE   CLIMACTERIC  PERIOD. 

teric  (Kali  brom.,  sang.,  sepia)  ;  also  hot  vertex,  metrorrhagia, 
and  fainting  at  this  time  (China,  nux  vom.,  ferrum)  ;  there  is 
painful  distension  of  the  abdomen  from  flatulence  (Carbo  veg., 
china,  lach.,  kali  carb.),  and  the  patient  can  bear  no  pressure  of 
the  clothes.  Not  infrequently  there  is  considerable  irritation 
from  the  left  ovary,  which  is  swollen,  indurated,  or  is  the  site  of 
neuralgic  pains.  She  wakes  in  the  morning  with  vertigo  and 
a  sense  of  great  exhaustion  or  weakness  of  the  body,  and  at 
times  suffers  from  headache  extending  into  the  root  of  the 
nose,  or,  less  frequently,  one-sided  or  occipital  pain,  extending 
into  the  neck  and  shoulders,  sleeplessness. 

I  Sanguinaria.  Dr.  Jousset'  considers  this  the  principal 
remedy  for  migraine  or  hemicrania,  especially  at  the  climacteric 
in  women  whose  menses  are  profuse.  He  uses  from  the  12th 
to  the  30th  dilutions  ;  vertigo,  rush  of  blood  to  the  head  with 
buzzing  in  the  ears,  and  flushes  of  heat ;  headache  in  paroxysms, 
beginning  in  occiput,  it  spreads  upward  and  settles  over  the  right 
eye ;  headache,  with  nausea  and  chilliness,  followed  by  flushes 
of  heat  extending  from  the  head  to  the  stomach ;  sometimes 
bilious  vomiting,  short  shooting  pains  in  the  head,  and  shiver- 
ing. The  headache  is  better  in  the  open  air,  from  lying  down, 
and  from  sleeping.  It  is  an  excellent  remedy  for  flushes  of 
heat  at  the  climacteric,  and  foetid  corrosive  leucorrhoea  at  this 
time  (Kreosote,  nit.  ac). 

The  following  remedies  are  also  useful :  — 
Sulphate    of   atropia    or   belladonna^    china,    crocus, 
digitalis,    ferrum,    kali    brom.,    lycopodium,    nux    vom., 
physostigma,  polygonum,^  sepia,  sulph.,  sulph.  ac,  ther- 
idion,  valerian,  veratrum  vir. 

'  Elements  de  Medecine  Pratique. 

^  Dr.  A.  E.  Small  states  that  he  has  found  the  infusion  of  smartweed  the  best 
remedy  for  superficial  ulcers  and  sores  on  the  lower  extremities  at  the  climacteric 
period,  both  locally  and  internally.  —  Practice  of  Medicine,  p.  815,  1886. 


AMENORRIKBA. 


'57 


CHAPTER    XI. 


AMENORRHCEA, 


I  IKE  other  anomalies  of  the  uterine  discharges, 
-J  insufficient  or  absent  menstruation  is  not  a  disease 
in  itself,  but  an  expression  of  some  abnormal  condition 
of  the  system,  when  it  occurs  during  the  generative  life 
of  a  woman,  except  during  pregnancy  and  lactation. 
In  the  latter,  it  is  purely  physiological,  and  need  not  be 
considered  here.     Its  forms  and  etiology  are  outlined 


in  the  following  table 


Suppressed 
flow 


Amenorrhoea    . 


Scanty  or  de- 
layed flow 


Retention  of 
flow 


f   Plethora. 

Mental  emotion,  such  as  fright,  anxiety,  disap- 
pointed love,  etc. 

Cold  and  wet,  such  as  wetting  the  feet  during 
the  menses. 

Exhausting  diseases,  such  as  tuberculosis,  or 
chlorosis. 
[   Sea-voyage,  or  change  of  climate. 
f   Lack  of  ovarian  stimulus,  mental  strain,  and 
overwork. 

Local  inflammation,  such  as  ovaritis. 

Imperfect  or  non  development  of  the  sexual 
organs. 

Atrophy  of  the  uterus  or  ovaries. 

Lack  of  fresh  air,  exercise,  and  good  wholesome 
food. 

Occlusion  of  some  portion  of  the  genital  canal. 
If  congenital,  it  is  usually  at  the  entrance  of 
the  vagina ;  if  not  congenital,  the  occlusion 
is  most  common  in  the  upper  third  of  the 
vagina.^ 


The  causes  of  the  first  two  forms  may  produce  either 
condition,  though  most  often  the  relations  are  as  classi- 
fied above. 

'  See  Atresia  of  the  Vagina.  • 


158  A  MENORRHCEA . 

Suppression  of  the  menstrual  flow,  from  mental 
emotion,  cold,  wet,  and  tuberculosis,  is  one  of  the  most 
common  disorders  the  physician  is  called  upon  to  treat. 
Amenorrhoea,  associated  with  a  slight  cough,  emaciation, 
or  rise  in  temperature,  for  any  length  of  time,  should 
always  be  looked  upon  with  grave  suspicion,  especially 
in  scrofulous  subjects,  as  it  is  not  infrequently  the 
forerunner  of  phthisis. 

The  effect  of  a  sea-voyage  on  emigrants,  in  producing 
amenorrhoea,  is  due  to  the  poor  fare  on  shipboard,  and 
the  change  of  climate  on  their  arrival,  rather  than  the 
voyage  itself.  The  latter,  in  fact,  is  one  of  the  best 
remedies  for  this  condition  in  those  who  have  been 
overworked  mentally  and  physically,  and  need  absolute 
rest :  among  these  belong  schoolgirls  just  entering  on 
their  menstrual  life,  and  young  women  who  have  been 
compelled  to  study  hard,  in  addition  to  the  demands  of 
society  and  fashion.  The  nerve-force  is  diverted  from 
the  natural  channels,  and  some  derangement  is  sure  to 
follow. 

On  personal  inquiry,  the  writer  has  been  surprised  to 
find  the  prevalence  of  amenorrhoea  in  young  women  from 
sixteen  to  twenty  in  our  colleges  and  seminaries.  This 
is  not  invariably  the  case,  however  :  Dr.  Hall,  of  Vassar 
College,  informs  me,  that,  of  sixty-six  girls  who  had 
studied  hard  preparing  for  college,  thirty-seven  report 
little  or  no  inconvenience  at  any  time  during  their 
menstrual  histories  ;  eleven  have  improved  since  their 
first  menses,  and  have  little  or  no  inconvenience  now  ; 
seven  are  slightly  more  inconvenienced  than  at  first, 
two  decidedly  more  so  ;  and  nine,  who  are  somewhat 
troubled,  report  no  change  since  the  function  was  first 
established.  Dr.  Hall  thinks  the  few  disturbances  of 
the  menses  which  occur  are  due  to  change  of  climate 
and  surroundings  rather  than  study.     Excluding  defec- 


■TREATMENT  OF  AMENORRHGZA.  159 

tive  development,  she  has  found  these  cases  the  most 
difficult  to  treat  while  pursuing  their  studies  ;  next  to 
these,  amenorrhoea  depending  on  ovaritis  has  proved 
very  stubborn. 

The  lack  of  fresh  air,  exercise,  and  proper  food,  very 
commonly  leads  to  defective  nutrition  and  chlorosis. 
Nature  is  obliged  to  close  the  safety-valve,  and  retain 
the  blood  for  the  use  of  the  body,  just  as  in  exhausting 
diseases. 

This  is  partially  compensated  for  by  a  watery  leucor- 
rhoea  instead  of  the  usual  flow.  It  need  not  be  viewed 
with  apprehension,  but  rather  shows  the  monthly  con- 
gestion of  the  pelvic  organs  is  taking  place,  and  that 
Nature  will  again  assert  herself  when  the  organism  can 
afford  to  lose  the  menstrual  blood. 

The  Prognosis  of  amenorrhoea  depends  largely  on  the 
exciting  cause.  If  the  latter  can  be  removed,  the  prog- 
nosis as  to  cure  is  very  favorable  ;  indeed,  there  are 
comparatively  few  incurable  cases. 

The  General  Treatment  is  indicated  by  the  above  ; 
i.e.,  remove  the  cause.  For  the  treatment  of  scanty 
and  painful  menstruation,  the  reader  is  referred  to  the 
chapter  on  dysmenorrhoea.  The  hot-water  foot-bath 
described  there  for  the  congestive  form  is  very  useful 
for  suppression  of  the  flow  from  cold  and  wet.  If  due 
to  a  low  vitality  of  the  system,  or  chlorosis,  hygiene  is 
of  prime  importance.  Well-ventilated  sleeping  apart- 
ments ;  exposure  to  the  sun's  rays,  with  exercise  in  the 
open  air,  either  walking,  riding  horseback,  or  playing 
tennis,  but  never  to  such  an  extent  as  to  make  the 
patient  feel  exhausted  afterwards  ;  plain  nutritious 
food,  mental  rest  in  schoolgirls,  physical  rest  at  the 
time  of  the  expected  monthly,  and  early  retiring-hours 
are  very  essential  for  a  cure. 

Milk  and  cocoa  are  the  best  drinks  ;   strong  tea  and 


l6p  AMENORRHCEA. 

coffee  are  sometimes  positively  injurious,  particularly 
the  former.  An  inquiry  into  the  patient's  habits  of 
eating  and  drinking  will  often  give  a  clew  to  the  best 
method  of  treatment.  These  measures  may  be  aided 
by  a  change  of  air  or  a  sea-voyage.  In  short,  the  great 
object  is  to  develop  robust  health  and  strength,  and 
Nature  will  see  to  it  that  the  menses  return  without 
the  interference  of  art.  Here,  forcing  remedies  and 
powerful  emmenagogues  would  do  positive  harm. 

The  patient  may  be  in  fairly  good  health,  but  suffers 
from  sudden  suppression  of  the  menses  ;  the  symptoms 
are  those  of  cerebral,  and,  less  often,  pelvic  congestion, 
dizziness,  flushed  face,  epistaxis,  together  with  a  feeling 
of  fulness  and  weight  in  the  pelvis,  especially  at  the 
time  when  the  next  period  should  appear.  In  these 
cases,  mild  emmenagogues  are  admissible  just  before 
and  at  the  expected  time  ;  enemas  of  quite  warm  salt 
and  water,  and  the  hot  foot-bath,  are  excellent  adju- 
vants. 

In  the  old  school,  ergot,  savine,  nux  vomica,  quinine, 
and,  quite  recently,  permanganate  of  potash,  two  grains 
three  times  a  day,  have  met  with  some  favor.  The 
peroxide  of  manganese,  sometimes  recommended  instead 
of  the  latter,  is  not  sufficiently  reliable  in  its  composi- 
tion. Besides  these,  a  combination  of  aloes,  iron,  and 
nux  vomica  has  been  largely  used.  Excellent  as  these 
may  seem  from  a  physiological  standpoint,  they  are 
inferior  to  the  following  remedies  if  a  careful  selection 
be  made. 

The  Faradic  current  is  useful  in  some  cases,  but  the 
indications  for  it  have  not  been  clearly  defined.  Begin 
with  it  about  a  week  before  the  time  for  the  flow  to 
re-appear,  and  employ  a  mild  current  every  other  day, 
about  twenty  minutes  at  a  sitting,  till  the  flow  appears, 
or  the  menstrual   epoch   has  passed.      Place  one  pole 


ELECTRICITY  FOR   AMENORRCEHA.  l6l 

—  it  makes  no  difference  which  —  on  the  hypogastric 
region,  the  other  over  the  sacrum.  This  is  also  worthy 
of  trial  in  non-development  or  atrophy  of  the  sexual 
organs.  As  a  rule,  however,  the  prognosis  will  be  very 
unfavorable  in  such  cases,  unless  the  treatment  be 
commenced  at  or  near  the  usual  age  of  puberty,  which 
is  very  seldom  done,  as  the  patient  generally  does  not 
apply  to  the  physician  till  a  much  later  period.  To  be 
of  any  benefit,  the  Faradic  current  should  be  used 
three  times  a  week  for  some  months,  and  no  stronger 
than  the  patient  can  easily  bear. 

In  infantile  or  non-developed  uteri,  the  wearing  of 
galvanic  stem  pessaries,  i.e.,  alternate  beads  or  disks 
of  copper  and  zinc  on  a  flexible  stem,  has  sometimes 
proved  beneficial.  It  is  necessary  for  the  patient  to 
wear  Thomas'  cup  pessary  to  retain  the  stem. 

The  question  naturally  arises,  when  does  amenorrhoea 
in  young  girls  demand  interference  .''  As  a  rule  for 
all  cases,  so  long  as  the  patient  is  perfectly  welly  leave 
her  alone  to  Nattire  aided  by  good  hygiene.  But  when 
the  menses  are  scanty  and  painful,  or  there  is  not  a 
drop  of  menstrual  blood,  notwithstanding  she  has  had 
all  the  symptoms  of  menstruation  for  a  continuous 
number  of  monthly  cycles  (imperforate  hymen),  a  thor- 
ough examination  is  imperatively  necessary  without 
further  delay.  Unless  there  is  a  faulty  or  inflamed 
condition  of  some  of  the  pelvic  organs,  local  treatment 
is  inadmissible,  and  quite  uncalled  for,  as  then  amenor- 
rhoea is  but  a  symptom  of  the  general  condition  of  the 
patient. 

As  in  dysmenorrhoea,  the  medical  and  hygienic 
treatment  should  be  of  a  .constitutional  character,  every 
symptom  between  the  menstrual  epochs  being  carefully 
considered.  If  the  flow  fails  to  appear,  continue  the 
same  plan  of  treatment  until  about  a  week  before  the 


1 62  AMENORRHCEA. 

period  should  come,  and  then  substitute  some  remedy- 
having  a  more  decided  action  in  promoting  a  menstrual 
flow.  This  may  be  aided  by  hot  foot  or  sitz  baths, 
which  are  of  Uttle  or  no  use  in  the  interval.  It  is 
hardly  necessary  to  add,  that  while  the  patient  is 
improving  in  general  health,  and  there  is- a  decrease 
of  morbid  symptoms,  the  same  remedy  had  better  be 
continued.  Even  if  the  flow  does  not  appear  for  two 
or  three  months.  Nature  will  assert  herself  in  time. 

THERAPEUTICS. 

I  Aconite  is  an  invaluable  remedy  for  sudden  suppression 
of  the  menstrual  flow,  from  a  chill,  fright,  or  vexation,  with  the 
usual  congestive  phenomenon  (Bell.,  glonoine,  plat.,  puis.), 
especially  in  plethoric  women.  Ovaritis  may  accompany  it, 
with  painful  urging  to  urinate,  and  high  fever,  also  anxiety  and 
great  restlessness.  The  best  results  from  it  will  be  obtained 
when  it  is  given  promptly  at  the  time  of  the  exciting  cause. 
If  a  number  of  days  have  elapsed,  and  the  next  period  does 
not  appear,  Pulsatilla  is  generally  more  suitable ;  less  often, 
lycopodium.  Riickert  records  a  case  of  six  months  suppression 
in  a  plethoric  young  woman,  with  prsecordial  anguish  and 
asthma,  which  was  entirely  relieved  by  aconite. 

Belladonna.  Amenorrhoea  in  plethoric  women ;  sudden 
sui^pression  of  the  flow,  with  much  pressure  and  throbbing  in 
the  head  (Aeon.,  glon.),  hsematemesis  ;  feeling  of  weight  and 
fulness  in  the  pelvic  organs.  When  amenorrhoea  is  due  to 
plethora.  Dr.  Hughes  recommends  belladonna  in  the  intervals, 
and  aconite  at  the  periods ;  epistaxis,  tickling  in  the  nose ; 
drawing  pains  from  the  sacrum  extending  down  the  thighs, 
much  bearing-down  in  the  pelvis,  and  profuse  sweat  before  the 
menstrual  flow. 

II  Calcarea  carb.  A  very  important  remedy  for  delayed 
menstruation  in  scrofulous  girls,  those  who  are  fleshy,  weak 
(with  large  abdomens),  fair  complexion,  perspire  very  easily 
about  the  head,  and  are  subject  to  acidity  of  the  stomach  and 


THERAPEUTICS  OF  AMENORRHCEA.  1 63 

constipation.  There  is  reason  to  believe  this  remedy  may 
avert  the  development  of  tuberculosis  in  these  cases.  Dr. 
Ludlam  says,  "  Abundant  experience  has  satisfied  me  that  the 
calcarea  carbonica  is,  perhaps,  the  most  prominent  and  useful 
remedy  for  the  relief  of  those  menstrual  irregularities  which 
are  incident  to  pectoral  disease." 

Glonoine.  Severe  throbbmg  in  the  head,  and  pale  face, 
with  amenorrhoea,  particularly  in  plethoric  women  ;  the  cerebral 
congestion  is  intense  from  the  sudden  suppression.  This  rem- 
edy acts  very  promptly,  if  at  all,  and  is  very  useful  at  the 
climacteric  period. 

II  Graphites  ranks  near  Pulsatilla  as  a  remedy  for  delayed 
or  tardy  menstruation  with  scanty,  pale  flow.  Dr.  C.  Wessel- 
hoeft,  who  has  recorded  a  number  of  cases  of  insufficient 
menstruation  treated  by  it,'  thinks  it  is  better  adapted  to 
patients  over  thirty  years  old,  and  is  to  the  climacteric  what 
Pulsatilla  is  in  youth.  Dr.  Dudgeon  has  shown  its  application 
to  amenorrhoea  with  indurated  ovaries,^  and  Hahnemann  recom- 
mended it  for  delayed  menstruation  associated  with  great 
constipation.  The  stools  are  offensive,  dark,  half-digested,  and 
lumpy,  united  by  mucous  threads.  The  skin  is  unhealthy,  with 
excoriations,  fissures,  or  itching  blotches,  from  which  exudes  a 
corrosive,  sticky,  watery  fluid.  The  patient  tends  to  obesity, 
and  her  troubles  to  become  chronic.  Dr.  Bonninghausen  ^ 
mentions  it  for  amenorrhoea,  with  itching  or  eczematous  spots 
between  the  fingers. 

Kali  carb.  Some  of  the  older  writers  state  that  they  prefer 
it  to  Pulsatilla.  Menses  do  not  appear  at  the  age  of  puberty, 
or  are  scanty,  of  a  pungent  odor,  acrid,  and  cause  an  eruption 
on  the  thighs ;  menses  suppressed,  with  anasarca  or  ascites. 
Dr.  Jahr  states  that  he  has  had  some  cases  which  could  only  be 
brought  around  by  this  remedy.  The  characteristic  symptoms 
of  sac-like  swelling  between  eyebrows  and  lids,  the  susceptibihty 
to  cold,  the  sticking,  stitching  pains,  and  aggravation  of  the 

'  New-England  Med.  Gazette,  vol.  xi.  p.  459. 
-  Brit.  Jour,  of  Horn.,  vol.  xxxi.  p.  1S3. 
3  Allg.  horn.  Zeitttjig,  vol.  xxxiv.  p.  252. 


164  AMENORRHCEA. 

symptoms  at  two  or  three  o'clock  in  the  morning,  will  aid  in 
selecting  the  remedy. 

Magnesia  carb.  Scanty  and  delaying  menses,  of  thick, 
pitchy  consistence,  and  dark  color ;  more  profuse  at  night  than 
in  the  daytime. 

Natrum  mur.  The  first  menses  are  delayed  or  scanty. 
The  patient  is  depressed  mentally,  and  suffers  from  severe 
headache,  constipation,  is  emaciated,  and  very  easily  fatigued. 

II  Pulsatilla.  While  this  is  the  chief  remedy  for  amenor- 
rhoea  from  exposure  to  cold  and  wet,  or  for  a  flow  which  is 
scanty,  too  late,  and  of.  short  duration,  it  is  often  abused  by 
prescribing  it,  in  every  case,  as  routine  practice.  It  is  very 
useful  for  delayed  first  menses  in  girls  of  a  mild,  tearful  disposi- 
tion, who  are  in  fairly  good  health ;  menstrual  suppression 
complicated  with  ophthalmia  or  supra-orbital  neuralgia.  The 
general  symptoms  should  be  considered  in  selecting  this  remedy. 
Dr.  A.  E.  Small '  records  a  case  cured  by  puis,  nut.,  when  puis, 
nig.  had  failed.  The  menses  were  delayed  and  irregular,  and 
the  young  woman  suffered  from  severe  pain  in  head,  back,  and 
stomach,  with  great  restlessness. 

Senecin  ix.  has  been  recommended  by  Dr.  Holcombe^ 
for  retarded  or  suppressed  menstruation.  The  patient  is  nervous 
or  hysterical,  and  does  not  sleep  well. 

Sepia.  Menses  are  scanty,  flow  dark.  Dr.  Jahr  recom- 
mends it,  next  to  Pulsatilla,  for  the  delay  of  the  first  menses  if 
there  is  a  leucorrhceal  discharge  instead,  with  determination  of 
blood  to  the  chest,  and  a  pale  face.  It  is  an  excellent  remedy 
for  the  discolorations  of  the  skin  and  face  in  women  subject  to 
menstrual  derangements. 

Serpentaria  virg.  Dr.  Marcy^  states  that  he  has  often 
used  this  medicine  for  suppressed  and  delayed  menses  from 
cold,  violent  emotions,  and  the  debility  consequent  on  fevers, 
with  marked  success. 

Sulphur.     Dr.  Jahr  ranks  sulphur  with  Pulsatilla  for  insuffi- 

'  Practice  of  Medicine,  p.  S14,  18S6. 

-  U.  S.  Med.  and  Surg.  Journal,  vol.  viii.  p.  44. 

3  Theory  and  Practice,  p.  512. 


THERAPEUTICS  OF  AMENORRHCEA. 


165 


cient  menstruation  with  pale  flow.  Tliere  is  pressure  in  the 
pit  of  the  stomach  during  the  menses,  and  the  patient  is  subject 
to  flushes  of  heat,  cramps  in  the  calves  of  the  legs  and  soles 
of  the  feet,  with  burning  in  the  latter  at  night,  rush  of  blood 
to  the  head,  and  heavy,  pressive,  frontal  headache,  especially  in 
the  morning,  or  on  the  vertex,  like  a  heavy  weight  on  top 
of  the  head. 

The  following  remedies  are  less  frequently  useful  :- 


Alumina, 

Amm.  carb.. 

Apis,' 

Appocynum  can., 

Arnica,^ 

Arsenicum, 

Aurum, 

Baryta  carb., 

Bryonia, 

Carbo  veg., 

Causticiim, 


China, 

Cicuta, 

Cimicifuga, 

Cocculiis,^ 

Co  nil  1 711, 

Ciipnim, 

Cyclamen, 

Digitalis, 

Dulcamara, 

Euphrasia,*^ 

Ferrum, 


Ferrum  et  strychnia, 

Hellebore, 

Helonin, 

Hyoscyamus, 

Jgnatia,^ 

(Iodine), 

Lachesis, 

Leptandria, 

Lycopodiuin^ 

Mercurius, 


'  Dr.  J.  R.  Coxe  ( Hering's  Amer.  Arzpfg.,  p.  287)  reports  a  case  of  amenorrhoea 
which  had  lasted  for  six  years,  cured  by  apis.  It  was  associated  with  violent 
headache,  rush  of  blood  to  the  head,  delirium,  swelhng  or  CEdema  of  the  legs  and 
some  of  the  abdomen. 

^  Girl,  aet.  18,  brunette,  well  developed;  menses  suppressed  by  a  chill  fifteen 
months  previous.  Puis.,  graph.,  sap.,  suiph.,  and  rhus,  given  without  benefit;  no 
symptoms  except  headache,  slight  pressive  pain  in  the  breast.  The  use  of  arnica 
12,  three  days  before  the  menstrual  period,  was  followed  by  the  appearance  of  the 
flow,  and  the  following  monthlies  were  more  profuse  than  the  first.  —  RUckert, 
Klinische  Erfahrungen,  vol.  ii.  p.  219. 

3  Dr.  Stens  relates  an  interesting  case  cured  by  cocculus  30.  Suppression  of 
the  menses  in  a  young  girl  was  accompanied  by  periodical  mania  with  intermissions 
of  two  or  three  weeks.  —  Allg.  Horn.  Zeitttng,  vol.  Ixxxix.,  No.  15. 

*  This  cured  a  case  reported  by  Dr.  W.  P.  Defriez,  characterized  by  the  peculiar 
symptom,  which  had  been  constant  for  some  months,  menses  regular  in  time,  but 
lasi  only  one  hour.  The  flow  at  the  next  monthly  after  the  use  of  euphrasia  lasted 
a  number  of  hours,  and  the  second  one  was  normal. 

s  Dr.  Ludlam  praises  this  combination  for  chlorosis,  also  ignatia.  —  Dis. 
Women,  p.  loS,  1881. 

^  Amenorrhcea  with  rheumatic  pains. 


i66 


AMENORRHCEA. 


Nitric  ac, 

Nux  mosch./ 

Opium,- 

Phosphoriis, 

Plumbum, 

Podophyllum,       Sarsaparilla, 


Polygonum  hydro-     Silicea, 


piper,^ 
Rhododendron, 
Rhus  tox., 
Sabadilla, 


Strontia, 
Veratrum  alb., 
Veratrum  vir., 
Xanthoxyluni,4 
Zincum. 


As  a  help  in  selecting  a  remedy,  the  following  digest 
has  been  prepared  for  suggestions  to  the  reader  :  — 

Amenorrhcea,  zvith  bleeding  in  some  other  portion  of 
the  body  than  the  uterus  at  the  menstrual  epoch.  —  (See 
Vicarious  Menstruation.)  Bell,  bry.  (ham.),  lach.,  mille- 
folium, phos.,  puis.,  sulph.,  veratr.  alb. 

Amenorrhcea  with  Cardiac  Disturbance.  —  (Compare 
remedies  for  chlorosis  and  debility.)  Ars.,  iodine,  lach. 
(lycopus  V.)  ;  also  aeon.,  apis,  bry.,  caust.,  cimicif.,  cupr., 
kali  carb.,  lil.  tig.,  nux  mosch. 

AnienorrJioea  with  Cerebral  Congestion  or  Headache.  — 
Aeon.,  bell.,  ferrum,  gels.,  glon.  (macrotin),  mere.  (nat. 
mur.),  opium  (silicea),  sulph.,  verat.  alb.,  verat.  vir. 

Amenorrho^a  with  Dropsical  Symptoms.  —  Apis,  appo- 
cynuni  can.,  ars.,  calc.  carb.,  hellebore,  kali  carb.,  mere. 

Amenorrhcea  with  Gastric  Aeffctiojts.. —  Aletris,  ars. 
(china),  helonine,  lycop.,  puis.  ;  also  kali  carb.,  lach., 
nux  mosch.,  nux  vom.,  podo. 

Amenorrhcea  zvith  Mammary  Symptoms.  —  Bry.,  cimi- 

'  This  promises  to  be  an  excellent  remedy  for  scanty,  irregular,  or  suppressed 
menses  from  cold,  with  the  characteristic  mental  and  head  symptoms.  Dr.  H.  C. 
Houghton  relates  a  case  of  suppression  of  the  flow  by  a  bath,  followed  by  intense 
labor-like  pains,  fainting  at  acme  of  pain,  recovering  with  a  start,  and  agonizing 
expression  of  the  face.  —  Hoyne's  Cliitic.  Therap.,  vol.  ii.  p.  96. 

^  Amenorrhcea  from  fright,  with  great  drowsiness. 

3  Dr.  A.  E.  Small  has  known  an  infusion  of  this  plant  (smartweed),  in  five- 
drop  doses,  to  succeed  in  delayed  menstruation  when  many  other  remedies  had 
failed,  and  has  used  it  with  "more  than  ordinary  good  results."  —  Practice  of 
Medicine,  p.  815,  1886. 

*  Dr.  C.  D.  Williams,  U.  S.  Med.  and  Surg.  Journal,  1871,  p.  35  ;  and  Raue, 
Clinical  Records,  p.  179,  1872,  and  p.  178, 1875. 


DIGEST  OF  REMEDIES  FOR  AMENORRHCEA.     1 67 

cifiiga    (china),    coniuni,    cyclamen,    dulcamara,    phos., 
puis.,  rhus  tox.  (silicea). 

Ainenorrhcea  with  Nervo7is  Phenomena,  chiefly  Hyster- 
ical. —  (See  Puberty  and  the  Climacteric  Period.)  Caus- 
ticum,  cicuta,  ciniicifuga,  cocculus  (coffea),  cuprum 
(cypripedium),  ferrum  (gels.),  hyosc.  (theridion). 

Ainenorrhcea  ivith  Congestion  of  the  Pelvic  Organs.  — 
Aeon.,  bell.,  cauloph.,  mere,  puis.,  sepia,  sulph. 

Ainenorrhcea  zvith  Skin  Eruptions. —  Carbo  veg.,  dulc, 
graphites,  kali  carb.,  sarsaparilla,  sepia,  sulph. 

Flow  Absent  or  Delayed  in  girls  old  enough  to  men- 
struate.—  Aeon.,  baryta  carb.,  apis,  calc.  carb.,  ciniicifuga, 
digitalis,  droscera,  graph.,  kali  carb.,  nat.  mur.,  puis., 
sepia,  silicea,  sulph. 

Flow  too  Early  and  Scanty.  —  (Compare  Dysmenor- 
rhoea.)  Alum.,  (ars  ,)  carbo  veg.,  cauloph.,  manganuni, 
nitric  ac,  phos.,  silicea. 

Flow  too  Late  or  Delayed,  and  Scanty.  —  Amm.  carb., 
aurum,  baryta  carb.,  conium,  cyclamen,  dulc,  graph. 
(lachesis  scanty,  may  be  too  early,  too  late,  or  regular, 
like  sepia),  lith.  carb.,  mag.  carb.,  nat.  mur.,  puis.,  sarsap. 

Flow  Intermittent.  —  Appocynum,  causticum,  crotalus, 
hyosc,  puis.,  sabadilla. 

Flow  at  Irregular  Periods.  —  Apis,  ciinicifuga,  iodine, 
nitric  ac,  nux  mosch.,  sabadilla,  sabina,  senecin,  staphi- 
sagria. 

Flow  suppressed  from  Chlorosis.  —  (Compare  chapter 
on  Puberty  and  the  Climacteric  Period.)  Ars.,  calc. 
carb.,  china,  conium.,  cyclamen,  ferrum,  ferrum  et 
strychnia,  ignatia,  nat.  mur.,  phos.,  plumbum,  puis. 

Flow  suppressed  from  Cold  and  Wet.  —  A^conitc,  bell., 
cimicifuga,  dulc,  gionoine,  nux  mosch.,  puis.,  rhus  tox., 
senecin  ;  also  cauloph.,  cham.,  gels.,  sepia,  sulphur. 

Flow  suppressed  from  Debility  —  (Compare  Chlorosis.) 
Aletris,  ars.,  china,  helonin,  nat.  mur.,  senecin. 


1 68  AMENORRHCEA. 

Flow  suppressed  from  Mental  Emotion  (fright,  anger, 
chagrin,  disappointment,  etc.).  —  Aconite,  causticum 
(china),  coloc,  conium,  hellebore,  ignatia,  lycop.,  opium, 
Pulsatilla. 

Flow  suppressed  from  Ovaritis.  —  Aeon.,  apis,  bell., 
cimicif.,  coni.,  lil.  tig.  (phytolacca),  (podo.),  thuja,  zincum. 

Leucorrhoea  in  place  of  the  Menses.  —  (Alumina),  ar- 
senicum  alb.,  china,  cocculus,  mix  mosch.,  phos.  (ruta 
grav.),  senecin,  sepia,  silicea. 


MENORRHAGIA   AND  METRORRHAGIA.       169 


CHAPTER    XII. 

MENORRHAGIA  AND  METRORRHAGIA. 

THE  former  term  means  profuse  menstruation  ;  the 
latter  applies  to  a  discharge  of  blood  from  the 
genitals,  between  the  menstrual  periods.  Neither  can 
be  considered  a  disease  in  itself,  but  is  secondary  to  or 
symptomatic  of  other  diseases,  such  as  :  — 

Fibroid  tumors  of  the  uterus. 

Polypoid  degeneration  of  the  endometrium  (endomet- 
ritis prolifera  or  hyperplastic  endometritis). 

Retention  of  the  placenta  after  abortion.  Sub-involu- 
tion.    Ovaritis. 

Engorgement  of  the  portal  circulation. 

Telluric  influences,  such  as  malaria. 

In  short,  a  persistent  flow  of  blood  from  the  uterus  is 
ofteit  due  to  some  neoplasm  or  groivth  within  that  organ, 
if  its  history  does  not  date  from  pregnancy .  There  are 
some  women  who  naturally  flow  very  profusely,  and  yet 
are  not  well  unless  they  do.  Such  persons  are  liable 
to  have  the  monthly  period  come  on  in  three  or  four 
months  after  confinement,  and  flow  so  severely  as  to 
make  them  anaemic,  hysterical,  and  seriously  interfere 
with  their  ultimate  reco\^ery,  unless  the  discharge  is 
controlled  in  some  manner. 

The  quantity  is  so  variable,  that  the  question  whether 
the  patient  is  flowing  too  much  should  be  decided  by 
its  effect  on  the  organism.  If  a  woman  flows  profusely, 
and  is  pale,  weak,  anaemic,  has  white  ears,  complains  of 


I/O      MENORRHAGIA    AND  METRORRHAGIA, 

dizzinessj  and  the  mucous  membrane  of  the  mouth  and 
tono-ue  is  pale  instead  of  pink,  there  is  reason  to  believe 
it  is  due  to  loss  of  blood.  In  all  cases  of  profuse  and 
persistent  flowing,  an  examination  should  be  made  to 
ascertain  the  cause,  and,  if  possible,  to  remove  it.  Some 
cases  depending  on  the  presence  of  foreign  growths, 
such  as  fibroids,  will  partially  and  occasionally  wholly 
vield  to  treatment,  so  that  the  patient  will  pass  safely 
through  the  climacteric  without  having  to  submit  to  a 
surgical  operation. 

In  many  cases,  this  can  hardly  be  hoped  for ;  and  the 
physician  should  be  careful  in  making  such  promises. 
This  question  will  be  considered  under  the  proper  chap- 
ters (see  Fibroid  Tumors,  Polypi,  etc.). 

The  Diet  should  be  generous  :  milk,  eggs,  beef  in 
some  form,  or  a  good  extract  of  it ;  mutton  chops ; 
strono-  broths  and  soups  in  small  quantities,  but  often. 
Lemonade,  oranges,  and  grapes  are  refreshing  to  the 
patient,  and  the  acid  m  them  seems  to  have  a  beneficial 
influence.  Stimulants  are  to  be  proscribed,  as  they 
often  do  more  harm  than  good,  except  in  rare  instances 
to  temporarily  revive  a  patient  with  tendency  to  syncope. 
Where  there  is  marked  anaemia,  I  have  sometimes  seen 
good  effects  from  the  use  of  beef,  wine,  and  iron  ;  but 
in  the  very  great  majority  of  cases,  patients  will  do 
much  better  without  it,  if  the  physician  carefully  selects 
the  one  remedy,  and  properly  feeds  his  patient. 

Local  Treatment.  —  In  many  cases  very  little,  if  any, 
is  necessary  other  than  the  removal  of  the  growths, 
if  present.  The  proper  remedy,  carefully  selected,  will 
prove  the  best  styptic.  Douches  of  hot  water  will  some- 
times diminish  the  flow  temporarily  ;  and  the  benefit  to 
be  derived  from  the  hot-water  spinal  bag  must  not  be 
foro-otten.  The  douches  can  be  repeated  as  often  as 
three  times  a  day  if  necessary,  and  if  the  patient  does 


TREATMENT  OF  MENORRHAGIA. 


171 


not  feel  exhausted  afterward.     In  severe  cases,  a  vaginal 
plug  may  be  resorted  to,  as  a  temporary 
measure.      Styptics,  astringents,  etc.,  have  IK  ' 

no  C7irative  value,  and  cannot  always  be 
depended  upon,  even  when  applied  directly 
to  the  source  of  the  hemorrhage. 

Among    the    simplest    applications    are 
tampons  squeezed  out  of  a  saturated  solu- 
tion of   alum,  and   crowded  close  against 
the  cervix.     When   these   are  taken    out, 
pledgets  of  glycerine  should  be  inserted, 
to  soothe  the  dry,   puckered  condition  of 
the  vagina.     Obstinate    cases,   depending 
on     polypoid    degeneration     (hyperiDlastic 
endometritis)  will  require  thorough  curet- 
ting, and  the  intra-uterine  application  of   p 
iodine,     either     by    Buttle's    or    Braun's  •? 
syringe,     or    by    cotton    wrapped   tightly    « 
round  a  uterine  probe  or  sound.     If   the    "^ 
hemorrhage  returns  in  a  few  weeks,  and    ^ 
will    not    yield    to    remedies,    the    curette    3 
should  be  used  again,  and  the  persulphate    ?> 
of  iron  applied  instead  of  the  iodine,  pref- 
erably in  a  solution  of   one  part   of   iron 
to  three  of  water.     Dr.  Martin  of  Berlin 
uses  fifteen  drops  of  undiluted  iron  with 
Braun's   syringe.      Though   I    have    often 
seen    him  do  this,   I   should  fear  serious 
results  in  the  hands  of  a  less  competent 
person  ;   and  believe  the  diluted  prepara- 
tion   quite    as    efficacious    and    far    less 
hazardous. 

An  invariable  rule,  never  to  be  forgot- 
ten, in  all  injections  into  the  uterine 
cavity,  is  to  have  the  cervix  well  dilated ; 


1/2      MENORRHAGIA    AND  METRORRHAGIA. 

even  then  it  may  contract,  and  the  imprisoned  fluid 
cause  great  pain,  or  escape  through  the  Fallopian  tubes 
into  the  peritoneal  cavity,  if  the  injection  tube  be  not 
double  so  as  to  provide  for  a  return  current. 

Sometimes  a  change  of  air  alone  will  cure  the 
patient. 

I  have  seen  a  lady  well  advanced  in  the  climacteric 
flow  very  profusely  and  continuously  at  the  seashore, 
without  receiving  any  benefit  from  local  or  internal 
treatment,  even  from  curetting  the  uterus,  and  the 
application  of  iodine.  But  on  removing  four  or  five 
miles  inland,  the  hemorrhage  ceased  in  a  short  time, 
and  she  became  perfectly  well. 

If  the  bowels  are  constipated,  and  hinder  free  portal 
circulation,  they  should  be  emptied  by  enemas.  Raising 
the  foot  of  the  bed  a  couple  of  inches,  and  keeping  the 
head  and  shoulders  low,  tends  to  lessen  the  amount  of 
blood  in  the  pelvis.  Plenty  of  fresh  cool  air,  cool  food 
and  drinks,  in  the  most  severe  cases,  are  advisable. 

In  some  cases  of  metrorrhagia,  from  an  atonic  con- 
dition of  the  uterus,  the  Faradic  current  has  been 
employed  with  success.' 

'  Mrs. ,  aet.  30.    Has  had  three  children,  and  one  abortion  at  three  months. 

Since  the  latter,  has  suffered  from  slight  but  constant  discharge  of  blood  from  the 
uterus,  A  careful  examination  showed  there  was  no  portion  of  the  placenta  re- 
tained, neither  a  tumor  nor  polypus  of  the  uterus  to  account  for  it.  Irrigation 
with  hot  water,  ergotin,  liquor  ferri,  and  plugging  of  the  vagina  were  tried,  without 
success.  The  hemorrhage  still  continued.  As  the  last  resort,  electricity  was  used. 
One  pole  of  the  Faradic  current  was  placed  on  the  hypogastrium,  the  other  was 
applied  to  the  neck  of  the  uterus.  The  patient  complained  of  pain,  but  the  bleed- 
ing stopped  in  five  minutes.  It  recurred  in  three  days,  but  disappeared  after  a 
more  prolonged  application  of  the  current ;  and  the  patient  recovered  completely, 
under  a  tonic  and  hydro-therapeutic  treatment.  —  Dr.  Ramos,  Btdlet.  General  de 
Therapeutique,  No.  i,  188&. 


THERAPEUTICS  OF   MENORRHAGIA,   ETC.     1 73 


THERAPEUTICS. 

Generally  speaking,  the  remedies  applicable  to  men- 
orrhagia  and  metrorrhagia  are  also  valuable  in  the 
therapeutics  of  abortion.  The  efficacy  of  medicine  is 
beautifully  illustrated  in  its  effect  on  uterine  hemor- 
rhage, if  it  be  of  non-puerperal  origin  ;  but  in  the 
majority  of  cases,  one  remedy  alone  will  not  be  suffi- 
cient to  cure  the  patient.  New  symptoms  may  arise, 
others  be  cured,  and  a  second  or  even  a  third  remedy 
must  be  substituted  for  the  one  previously  given.  In 
prescribing  for  the  conditions  under  consideration,  the 
ovarian  symptoms  accompanying  the  flow  are  of  great 
importance,  and  should  be  carefully  ascertained. 

Arsenicum.'  Menses  too  early,  too  profuse ;  exhausting 
menorrhagia;  hemorrhage,  with  lancinating,  burning  pains, 
especially  in  the  right  ovary.  If  there  is  also  chronic  endo- 
metritis. It  is  not  a  common  remedy,  but  has  proved  curative 
in  some  obstinate  cases  in  material  doses.- 

II  Belladonna. 3  The  uterine  and  menstrual  symptoms 
resemble  sabina,  but  the  general  condition  of  the  patient  is 
characteristic  of  bell.  Great  pressure  downward  in  the  geni- 
tals, as  if  the  contents  of  the  abdomen  would  protrude  through 
the  vulva  (Lil.  tig.,  plat.,  sepia)  ;  menses  too  early  and  too  pro- 
fuse (Calc.  carb.,  nux  vom.)  ;  bright  red  (Ham.,  ipecac),  or 
thick,  decomposed,  dark  red  blood  which  feels  hot  to  the  parts  ; 
burning,  throbbing  in  the  right  ovary  ;  tremulous  feeling  through 
the  whole  body.  Gentle  pressure  on  the  uterus,  or  motion  of 
the  hands  and  feet,  causes  vertigo  and  nausea,  without  retching 
or  heaving.  Dr.  Carroll  Dunham  recommended  it  for  offensive 
metrorrhagia,  and  for  extremely  offensive  menstruation  in  young 
unmarried  women. 

1  Hughes'  Pharmacodynamics,  4th  ed.  p.  250. 

2  Hahn.  Mat.  Med.,  part  i.  p.  18,  Ars. 

3  Hahn.  Monthly,  December,  1S70,  Dr.  O.  P.  Baehr. 


174      MENORRHAGIA    AND  METRORRHAGIA. 

1  Calcarea  Carb.  is  an  invaluable  remedy.  It  is  indi- 
cated by  the  general  conditions  and  symptoms  of  the  patient, 
rather  than  those  peculiar  to  the  sexual  organs.  Menses  too 
early,  last  too  long,  and  are  too  profuse  '  (Bell.,  nux  vom.)  ;  leu- 
corrhoea  like  milk  (Conium,  \yc.,  puis.,  sepia,  sulph.  ac),  with 
itching  and  burning  in  the  genitals,  strumous  diathesis,  and 
tendency  to  pectoral  disorders  -jfeet  feci  cold  and  damp  ;  much 
sweat  on  labia,  and  sweating  of  the  feet.  Dr.  Guernsey  recom- 
mends calcarea,  and  also  silicea,  for  menorrhagia  in  nursing 
women. 

I  Chamomilla.  The  mental  symptoms  are  important.  The 
flow  is  dark  and  clotted ;  the  clots  large,  and  associated  with 
severe  labor-like  pains  in  the  uterus ;  drawing,  griping  pains 
frofn  the  sacrum  or  small  of  back  forward  to  the  pubic  bones. 
The  pains  are  followed  by  the  discharge  of  clots.  The  menses 
are  too  early,  profuse,  and  sometimes  offensive.  The  metror- 
rhagia is  in  paroxysms. 

China.  This  remedy  is  not  only  of  great  value  in  relieving 
the  debility  from  loss  of  blood,  but  it  also  has  symptoms  of 
its  own,  resembling  crocus.  It  can  be  given  with  advantage 
between  the  periods,  in  case  of  antemia,  —  here  I  prefer  the 
second  or  third  trituration  of  the  bark,  —  while  some  other 
remedy,  such  as  crocus,  is  used  instead  at  the  time  of  the  flow. 
Cases  of  malarial  origin,  where  the  symptoms  show  a  marked 
periodicity,  and  also  for  women  suffering  from  sexual  excesses. 
Profuse  perspiration  at  night ;  patient  complains  of  being  chilly, 
with  thirst  before  or  after  the  chill ;  menses  too  early,  profuse, 
black  clots,  with  spasm  in  chest  and  abdomen. 

Cinnamon.^  Well  recommended  by  Dr.  Winterburn,  where 
the  flow  comes  on  suddenly,  is  profuse,  and  of  a  bright  red 
color. 

II  Crocus. 3     Metrorrhagia  of  dark,  viscid,  stringy  blood,  in 

^  Hahnemann  states  that  if  the  menses  appear  at  the  regular  period,  or  later, 
calcarea  will  do  no  good,  even  if  they  are  not  scanty. 

2  Arndt's  System  of  Medicine,  vol.  ii.  p.  393. 

2  Dr.  Moffat  states  that  it  induced  metrorrhagia  in  a  lady  medical  student,  vi^ho 
tried  to  ascertain  if  it  would  cause  it.  —  North  Amer.  Jour,  of  Horn.,  May,  1883. 

3  Hughes'  Pharmacodynamics,  4th  ed.  p.  443. 


THERAPEUTICS   OF  MENORRHAGIA,   ETC.     175 

diack  clots,  worse  from  least  motion;  functional  raenorrhagia, 
particularly  in  young  women.     I  prefer  the  2X.  dilution. 

Digitalis.  Where  the  flow  is  secondary  to  engorgement  of 
the  portal  circulation,'  especially  if  from  cardiac  disease,  and 
the  symptoms  present  indicate  digitalis.  Symptoms  of  passive 
venous  congestion  prevail ;  the  face  is  pale  or  livid,  and  the 
skin  cold.  In  these  cases,  it  may  be  necessary  to  use  it  strong 
enough  for  physiological  effects. 

Hamamelis  2x.  If  the  flow  be  passive,  small  amount, 
but  continuous,  color  usually  dark,  may  be  bright.  If  there  be 
a  heviorrhagic  diathesis,  and  tendency  to  venous  engorgement, 
menorrhagia  associated  with  sub-acute  ovaritis,  the  blood  slowly 
trickles  away,  and  is  not  coagulated.  Dr.  D.  Dyce  Brown  ^ 
recommends  hamamelis  for  uterine  hemorrhage,  especially  if 
abortion  is  threatened,  or  if  it  follows  abortion.  The  flow  is 
more  often  dark,  venous  (Erigeron,  arterial),  but  he  does  not 
Hmit  its  action  to  any  color  of  the  discharge. 

I  Ipecac.  Me?ises  too  early,  profuse,  and  of  bright  red 
blood,  which  coagulates  readily.  It  is  accompanied  by  nausea, 
great  weakness,  and  cutting,  griping  pains  in  the  abdomen. 

I  Magnesium  Carb.  Menses  delayed.  The  discharge 
is  usually  viscid  and  glutinous,  but  may  be  coagulated.  A 
peculiar  symptom,  often  verified,  is  that  the  flow  is  more  pro- 
fuse at  night  than  in  the  daytime. 

Nitric  acid  3  has  been  found  very  useful  for  menorrhagia  or 
long-continued  passive  or  irregular  hemorrhage,  after  abortion 
(Secale  cor.),  confinement,  or  at  the  climacteric  (Vinca  min.); 
bearing-down  in  hypogastrium,  pain  down  the  thighs,  needle- 
like pains  in  the  body ;  urine  strong,  like  horse's  urine ;  aching 
in  the  rectum,  after  stool ;  loss  of  strength  and  appetite  ;  head- 
ache ;  weak,  irregular,  sometimes  rapid  pulse,  and  other  symp- 
toms of  anaemia ;  flow  shreddy  and  dark-colored. 

'  Cardio-Uterine  Remedies.  —  E.  M.  Hale,  M.D.,  Am.  Horn.  Jour,  of  Gyn. 
and  Ob  St.,  August,  1885. 

^  Monthly  Horn.  Review,  Aug.  i,  p.  473,  1870. 

3  Dr.  Ludlam  reports  a  case  of  menorrhagia  witli  remittent  fever,  and  a  ver}' 
obstinate  case  of  menorrhagia  alternating  with  convulsions,  cured  b)-  nitric  ac.  6x* 
—  Dis.  Women,  pp.  262  and  266. 


1/6       MENORRHAGIA    AND   METRORRHAGIA. 

I  Nux  Vomica.  The  mental  and  other  general  symptoms 
are  important.  The  menses  are  too  early  and  too  profuse ; 
during  the  menses,  nausea  in  the  morning,  with  chilliness, 
attacks  of  faintness,  and  pressure  toward  the  genitals.  The 
symptoms  are  worse  in  the  morning  after  eating,  from  motion, 
and  in  the  open  air ;  great  irritability  of  the  nervous  system. 

I  Platina.  Menses  too  early  and  too  profuse,  last  too  long, 
discharge  dark  and  thick ;  may  be  clotted,  and  accompanied 
by  bearing-down  pains  in  the  abdomen  (Bell.,  sepia).  There 
is  increased  sexual  desire,  particularly  after  the  flow  ceases  ; 
also  painful  sensitiveness  and  constant  pressure  in  the  mons 
veneris  and  genital  organs  ;  body  feels  cold,  except  the  face  ; ' 
hypersensitiveness  and  irritability  of  the  genital  organs ;  the 
patient  has  the  most  exalted  self-esteem  ;  premature  develop- 
ment of  sexual  instinct ;  and  for  older  women  when  the 
metrorrhagia  is  associated  with  melancholia. 

II  Sabina.  Dr.  Hughes  recommends  its  use  both  during 
and  between  the  periods  ;  ^  metritis  accompanied  by  flooding;  ^ 
menses  too  early,  too  profuse,  last  too  long;  hemoirhage  from 
the  uterus  in  paroxysms  (Trillium),  worse  from  motion,  blood 
dark  and  clotted,  or  may  be  light-colored  and  florid  ;  after  abor- 
tion or  labor  ;  pain  from  back  to pjcbis.  Increased  sexual  desire. 
Hering  states  that  the  metrorrhagia  is  increased  by  the  least 
motion,  but  often  better  from  walking. 

1 1  Secale  cor.  has  been  recommended  for  uterine  hemor- 
rhage, when  the  uterus  is  atonic  and  hypersemic,  in  doses  of  the 
tincture  sufficient  to  secure  uterine  contraction.  It  is  also  use- 
ful in  dilutions,  but  in  either  case  the  preparation  must  be  fresh. 
Hemorrhage  from  the  uterus,  worse  f-om  the  least  motion  ;  dis- 
charge black,  fluid,  and  very  fetid,  also  if  it  is  attended  with 
labor-like  pains.  Dr.  Kafka  '^  states  that  he  has  used  ergotin  in 
many  cases  of  profuse  menstruation,  especially  for  women  who 
have  given  birth  to  many  children  near  together,  when  the  flow 


'  Lectures  on  Materia  Medica,  C.  Dunham,  vol.  ii.  p.  135. 

^  Manual  of  Therapeutics,  Hughes,  p.  2S3. 

3  Brit.  Jour,  of  Horn.  xxi.  p,  342. 

'*■  Allgemeine  Horn.  Zeitung,  No.  55,  p.  114. 


THERAPEUTICS   OF   MENORRHAGIA,   ETC.     \77 

was  perfectly  painless  and  increased  by  the  least  active  or  passive 
motion,  and  never  has  known  it  to  fail. 

I  Trillium.  Hemorrhagic  diathesis ;  flow  returns  every 
fortnight  (Plat.),  with  yellowish  creamy  leucorrhoja  during  the 
intervals  ;  the  flow  is  of  bright  color,  and  comes  in  gushes  on 
the  least  motion  (Sabina),  It  is  especially  suitable  to  the 
climacteric,  and  has  been  used  with  success  for  uterine  hemor- 
rhage depending  upon  the  presence  of  fibroid  tumors.' 

Tarantula  has  been  recommended  by  Dr.  Jousset,  if  the 
type  of  the  fever  accompanying  a  menorrhagia  is  intermittent.- 
Nit.  ac.  2x.  has  been  used  successfully  for  similar  cases. 

The  following  remedies  are  less  frequently  used,  but 
may  be  referred  to  if  none  of  the  preceding  ones  seem 
to  be  indicated  :  — 

Aeon.,  aloe,  ambra,  ainmon.  carb.,  apoc.  can.,  argent- 
um,  arnica,  borax,  bovista,  bryonia,  caust.,  carb.  veg., 
carbol.  ac,  cimicifuga,  coffea,  cyclamen,'^  erechthites, 
erigeron,  ferrum,  helonias,  hepar  sulph.,  hydrastis,4 
hyosc,  ignatia,  ferrum,  kali  carb.,  kreosote,  lycop.,  lau- 
rocerasus,5  millefolium,  mere,    nat.  mur.,    phos.,  puis., 

'  Ludlam  :  Dis.  Women,  p.  99S. 

2  Lectures  on  Clinical  Medicine,  Jousset,  p.  46. 

3  Mrs. .    The  menstruation  was  very  profuse,  obliging  her  to  lie  down,  and 

always  accompanied  by  the  discharge  of  a  membrane  ;  flow  profuse,  dark,  and  clotted. 
Eighteen  months  previous  slie  had  a  miscarriage,  and  was  ill  for  five  weeks  ;  since 
then  she  has  had  this  menorrhagia,  and  thirty-six  hours  after  the  flow  commences, 
a  little  membranous  bag  is  discharged,  rarely  in  shreds,  and  without  pain. 
Cyclamen  3X.  was  given,  and  the  membranes  appeared  only  once  afterwards,  and 
the  menses  became  normal.  —  Dr.  A.  C.  Pope  :  Monthly  Horn.  Revieiv. 

^  Hydrastis  has  been  recently  considered  almost  a  specific  for  menorrhagia  and 
metrorrhagia,  in  doses  of  twenty  drops  of  the  fluid  extract  three  or  four  times 
a  day.  Though  many  cases  have  been  reported,  the  exact  symptoms  indicating 
the  drug  have  not  yet  been  defined,  and  it  must  be  used  empirically.  Dr.  \A'ilcox 
has  given  a  summary  of  Schatz's  paper  (who  introduced  it  for  uterine  hemorrhage), 
the  results  of  other  experimenters,  and  brief  records  of  forty-three  cases,  in  which 
he  employed  the  remedy  with  generally  good  effect.  (See  New- York  Med.  Journal, 
p.  199,  Feb.  19,  1887.) 

5  Dr.  J.  L.  Arndt  has  found  this  very  useful  in  the  tincture  for  severe  uterine 
hemorrhage,  with  extreme  prostration,  especially  at  or  after  the  climacteric,  and 


178      MENORRHAGIA   AND  METRORRHAGIA. 

rhus  tox.,  ruta  grav.,  sepia,  silicea,  sulph.,  ustilago,  veratr. 
alb.,  vinca  m.  ix.,'  zinc. 

In  patients  predisposed  to  hemorrhage,  i.e.,  of  a  hem- 
orrhagic diathesis,  Dr.  Ludlam  recommends  one  of  the 
following  remedies  :  china,  ipecac,  sabina,  platina,  secale 
cor.,  ferrum,  nux  vom.,  nat.  mur.,  hamamelis,  trillium, 
rhus  tox.,  calc.  carb.,  bell.,  crocus,  carb.  veg.,  phos.,  ars. 
alb.,  sulphuric  acid,  nitric  acid. 

If  associated  with  a  scrofulous  diathesis,  he  uses 
calc.  carb.,  calc.  phos.,  hepar,  silicea,  baryta  carb.,  iodine, 
Phytolacca,  carbo  veg.,  mezereum,  mere,  sol.,  mere,  iod., 
nitric,  muriatic,  or  sulphuric  acid. 

In  obstinate  cases  of  passive  uterine  hemorrhage,  when 
carefully  selected  remedies  fail,  try  those  of  an  anti- 
syphilitic  nature ;  such  as,  kali  iod.,  thuja,  mere,  precip. 
ruber,  and  nitric  acid. 

In  chronic  cases  associated  with  ovaritis,  which  may 
have  preceded  the  abnormal  flowing,  try  bell.,  colocynth, 
hamamelis,  lilium  tig.,  lach.,  carb.  veg.,  sepia,  conium, 
veratr.  vir.,  platina,  mere,  cor.,  puis. 

Menstruation  oftener  than  once  in  twenty-eight  days, 
and  scaiity.  —  Asafoetida,  (cactus,)  carbo  an.,  mangan. 
acet.,  phos.,  sarsap. 

Menstritation  oftener  than  once  in  twenty-eight  days, 
and  profuse.  —  Aloe,  amm.  carb.,  arg.  nit ,  ars.,  bell., 
borax,  bovista,  bromine,  bry.,  calc.  carb.,  canth.,  carbo 
veg.,  caust.,  cham.,  china,  cocc,  cycla.,  ipecac,  kreosote, 
mezereum,  mur.  ac,  nux  vom.,  plat.,  sabina,  stannum, 
sulph.,  trilliim. 

Menstruatioji  delayed  beyond  twenty-eight  days,  and 

reports  three  cases  in  Hoyne's  Clinic.  Therap.,  vol.  ii.  p.  300,  The  symptoms  call- 
ing for  it  are :  too  early  and  too  profuse  menstruation ;  blood  thin,  liquid ;  with 
stupor  or  coma,  and  nightly  tearing  in  the  vertex. 

'  Dr.  Hughes  has  found  this  useful  to  check  passive  uterine  hemorrhage  occur- 
ring in  women  long  past  their  climacteric. — Manual  of  Phar)iiacody7ia7nics, 
p.  909,  1S86. 


REMEDIES  FOR  MENORRHAGIA,  ETC.        1 79 

scanty. — Aeon.,  alumina,  amm.  carb.,  aiir.,  bov.,  cocc, 
coni.,  drosc,  dulc,  euphrasia,  graph.,  helonias,  lycop., 
lith.  carb.,  mag.  carb.,  puis. 

Menstruation  delayed  beyond  twenty-eight  days,  and 
profuse.  —  Chelidonium,  ferrum,  kali  iocl.,  staphisagria. 

Menstruation  protracted.  —  Aeon.,  calc.  carb.,  carbo 
an.,  caust.,  china,  crocus,  ham.,  lycop.,  mez.,  nux  vom., 
plat.,  sabina,  seeale,  silicea,  trillium,  ustilago. 

Menstruation  irregular.  —  Arg.  nit.,  cimicifuga,  iodine, 
nit.  ac,  nux  mosch.,  puis.,  silicea,  staphisagria. 

Blood  bright  red.  —  Aeon.,  bell.,  brom.,  cimiamon, 
erigeron,  ham.,  hyosc,  ipecac,  millefol.,  sang.,  trillium. 

Blood  decomposed,  dark  red  {fluid).  —  Bell.,  bry., 
carbo  an.,  hamamelis. 

Blood  black,  almost  iiiky.  —  Cactus,  canth.,  cyclamen, 
kali  7iit.,  seeale,  sulphur. 

Blood  black  and  clotted. — Amm.  carb.,  cham.,  china, 
eimieif.,  coffea,  crocus,  cyclamen,  ignatia,  kreosote,  lach., 
lycop.,  mag.  carb.,  platina,  puis.,  sabina,  seeale,  ustilago. 

Blood  dark,  viscid,  stringy.  —  Cactus,  crocus,  amm. 
carb.,  cyclamen,  ignatia,  mag.  carb.,  platina. 

Blood,  offensive  odor.  —  Bell.,  bry.,  carbo  veg.,  caust., 
cham.,  helonias,  ignatia,  kreosote,  sang.,  seeale  (silicea), 
(sulph.). 

Blood  acrid,  makes  thighs  sore.  — Amm.  carb.,  aurum, 
carbo  veg.,  caust.,  kali  carb.,  lach.,  rhus  tox.,  sarsap., 
sulphur. 

Exhaustion  or  fatigue  during  or  after  the  floiv.  — 
Alumina,  amm.  carb.,  ars.  alb.,  carbo  an.,  china,  cocc., 
erigeron,  ferrum,  helonias. 

Well  only  during  menstruation.  —  (Mental  condition, 
Stan  num.)     Zinc. 

Flow  only  in  the  morning.  —  Sepia. 

Flow  only  in  the  moaning  and  evening.  — Phellandrium. 

Flow  more  profuse  early  in  the  morning.  —  Bovista. 


l8o      MENORRHAGIA   AND  METRORRHAGIA. 

Flow  only  during  the  day.  —  Caust.,  puis. 

Flow  djiring  the  day,  and  especially  while  walking.  — 
Puis. 

Flow  ceases  in  afternoon.  —  Magnes.  carb. 

Floiv  lessens  in  afternoon.  —  Magnes.  carb. 

Floiv  increases  in  afternoon.  —  Sulphur. 

Flow  zvorse  at  night. — Amm.  mur.,  bovista/  mag. 
carb.,  zinc. 

Flow  07tly  at  nigJit.  —  Bovista.'  Only  iti  the  evening, 
coffea. 

I  Miss. ,  aet.  33.  Previous  health  fairly  good.  The  menstrual  flow  ap- 
peared at  proper  time,  but  did  not  cease.  It  was  painless,  slightly  clotted,  of  a 
brighter  red  than  during  the  menstrual  flow  proper,  and  in  sufficient  quantity 
to  necessitate  a  change  of  cloths  every  four  or  five  hours.  The  marked  features 
of  the  case  were  :  absence  of  aggravation  from  moving  about ;  the  decided  increase 
of  the  flow  at  night  in  bed ;  the  appearance  of  the  discharge,  as  the  continu- 
ation of  the  normal  catamenia,  and  the  total  absence  of  any  local  or  constitutional 
symptoms  to  account  for  its  existence.  Ipecac,  nux  vom.,  secale,  cham.,  millefolium, 
puis.,  and  ars.  were  given  till  the  time  of  the  next  monthly,  which  amounted  almost 
to  flooding;  sabna  and  china  also  failed.  A  very  careful  physical  examination 
revealed  nothing  except  a  relaxation  of  the  vagina  near  the  cervix ;  the  uterus  high 
up  in  the  pelvis,  congested,  and  perfectly  movable.  The  condition  of  the  patient 
was  now  desperate.  A  pledget  of  Imt  soaked  in  dilute  tincture  of  iron  was  placed 
against  the  cervix,  and  the  vagina  firmly  packed.  This  did  no  good,  nor  did  the 
injection  of  two  drachms  of  dilute  tinct.  muriate  of  iron  into  the  cervical  canal ; 
ergot  in  formidable  doses  was  of  no  effect.  Bovista  4X.  trit.  every  half-hour  was 
then  given ;  uterine  contractions  were  produced  at  short  intervals  after  the  third 
dose.  She  continued  to  improve  from  this  time,  and  made  a  perfect  though  slow 
recovery,  with  the  help  of  ferrum,  ars.,  crocus,  and  cocculus.  There  has  been  no 
return  of  the  hemorrhage.  —  Dr.  W.  Wesselhoeft:  New-England  Medical 
Gazette,  p.  461,  vol.  ii.  1876. 

'  Mrs. .  Menstruation  always  profuse.  After  bearing  children  her  cata- 
menia became  a  fearful  menorrhagia,  completely  exhausting  her.  There  was  noth- 
ing particularly  characteristic,  further  than  a  wonderful  flow  of  blood,  and  an 
amelioration  during  the  daytime  when  on  her  feet,  and  an  aggravation  at  night 
when  lying  down.  This  condition  continued  for  months;  all  remedial  agencies 
brought  no  relief  through  allopathic  therapeutics,  further  than  terrible  spasms  of 
the  uterus,  apparently  brought  on  by  an  indiscriminate  use  of  ergot.  After  ex- 
hibiting remedies  as  they  occurred  to  me,  and  then  only  palliatives,  as  they  would 
not  control  the  hemorrhage  flow,  I  administered  bovista,  and  she  recovered.  During 
this  trouble  her  attendant  advised  her  to  become  pregnant,  which  seemed  impossi- 
ble although  during  thirteen  months,  to  use  her  own  words,  "we  never  tried  to 
prevent."  Three  months  after  taking  bovista  she  became  pregnant,  when  they 
did  try  to  prevent,  and  was  delivered,  at  full  term,  of  a  fine  healthy  boy.  —  Dr. 
Isaac  Cooper  :  Halui.  Month.,  p.  168,  November,  1S74. 


REMEDIES  FOR  MENORRHAGIA,  ETC.         l8l 

Flow  ceases  at  night.  —  Caust.  (puis.). 

Flow  ceases  on  lying  down.  —  Cactus,  grand.,  causti- 
cum. 

Flow  only  during  sleep  ^r  absence  of  pain.  —  Mag.  carb. 

Flow  between  the  periods.  —  Ambra,  bell.,  bovista 
(caust.),  hepar,  raangan.  acet.,  silicea. 

During  menstruation,  nausea. — Apoc.  cann.,  capsi 
cum,  ipecac,  kali  bi.,  nux  vom.,  puis.,  viburn.  op. 

During  menstruation,  diarrhoea.  —  Bovista,  caust, 
(erig.). 

During  menstruation,  eruption  on  the  skin.  —  Dulc, 
kali  carb.,  sarsap. 

Flow  less  on  motion.  —  Cyclamen.' 

Flow  worse  on  motion.  —  Arg.  met.,  cocc,  coffea, 
crocus,  erig.,  nit.  ac,  puis.,  sabina,  secale,  trillium,  usti- 
lago,  zinc. 

Flow  too  profuse  at  the  climacteric.  —  Lachesis,  lauro- 
cerasus,  nitric- acid,  secale  cor.,  trillium,  ustilago,^  vinca 
minor. 

'  Mrs. ,  aet.  44  ;  always  well  till  within  two  months.  The  flow  had  con- 
tinued all  through  each  month  ;  discharge  pale  and  watery,  at  first  dark  and  clotted  ; ' 
general  appearance  somewhat  exsanguinated ;  mouth,  tongue,  and  lips  pale ;  she 
always  felt  best  when  moving  about;  the  flow  almost  ceased  as  long  as  she  was 
moving  about  at  work,  but  as  soon  as  she  sat  down  quietly  in  the  evenijtg  thcflo'u 
re-appeared,  and  continued  after  she  went  to  bed.  Cyclamen  2x.  relieved  her 
promptly  ;  she  improved  in  general,  and  continued  so,  the  menses  returning  monthly 
until  March,  1873,  when  the  troubles  of  the  last  year  re-appeared.  After  two  doses 
of  the  same  remedy  she  remained  well.—  H.  Ring:  Raue'' s  Record  Hom.  Lit., 
P-  233,  1874. 

^  Mrs.  ,  aet.  40  ;  had  always  been  subject  to  profuse  menstruation,  sterile  ; 

was  a  large,  fleshy,  flabby,  bloated-looking  woman,  with  a  very  sallow  complexion, 
inclined  to  be  (and  formerly  had  been)  dropsical  from  excessive  loss  of  blood ; 
profuse  menstruation,  which  seems  to  her  to  be  principally  "  water  and  clots  ;  " 
she  says  there  is  no  outward  flow  when  she  lies  still,  but  the  clots  pass  out  of  the 
uterus  when  she  gets  up,  and  also  water ;  she  feels  so  full  in  the  uterus  that  she 
must  rise  to  get  rid  of  the  clots.  She  received  sabina,  which  did  not  arrest  the 
flooding.  At  my  second  visit  in  the  afternoon  she  seemed  better,  and  I  believed 
that  sabina  was  the  right  remedy.  But  %\^s.  flowed  fearfully  during  that  flight: 
when  I  saw  her  in  the  morning,  she  was  no  longer  able  to  rise  to  get  rid  of  the 
clots  ;  the  flow  still  continued ;  she  was  very  low,  scarcely  able  to  speak  aloud,  and 


1 82      MENORRHAGIA   AND  METRORRHAGIA. 

in  a  most  critical  condition.  Ustilago  maidis,  in  the  tincture,  was  prescribed  mixed 
with  water.  From  the  moment  of  commencing  to  take  it  she  improved ;  but  she 
had  been  so  reduced  by  the  enormous  loss  of  blood,  that  it  was  two  or  three  weeks 
before  she  was  able  to  sit  up  a  little.  After  six  months  there  has  been  no  return  of 
the  trouble  ;  she  has  improved  in  health,  and  her  old  trouble  seems  to  have  left  her 
for  good.  Hale  in  his  "New  Remedies"  gives  as  a  characteristic,  menorrhagia 
at  the  climacteric  period ;  active  and  constant  flowing,  with  frequent  clots.  — 
Dr.  J.  H.  P.  Frost:  Hahnemajinian  Monthly,  p.  145,  November,  1S74. 


VICARIOUS  MENSTRUATION.  1 83 


CHAPTER   XIII. 

VICARIOUS    MENSTRUATION. 

THIS  name  has  been  given  to  a  periodic  flow  of  blood 
from  som"e  other  portion  of  the  body  than  the 
uterus,  at  the  menstrual  epoch.  As  a  rule,  it  is  from 
some  mucous  membrane.  There  is,  however,  scarcely 
any  part  of  the  body  from  which  it  has  not  been  known 
to  occur.  The  most  common  places  are  the  nose, 
stomach,  hemorrhoidal  tumors,  lungs,  breasts,  and 
ulcers.  Instead  of  a  discharge  of  blood,  there  may  be 
a  serous  transudation,  and  the  patient  suffers  for  the 
time  with  a  profuse  watery  diarrhoea. 

The  most  common  cause  is  a  poor  state  of  health  or 
faulty  nutrition.  In  other  cases,  it  seems  to  be  due  to 
high  arterial  tension,  and  a  slight  discharge  of  blood 
may  precede  the  regular  flow  from  the  uterus  by  a  few 
hours.  In  a  case  of  this  kind  now  under  my  care,  it 
comes  from  the  right  nipple.' 

When  it  is  seen  in  young  women  who  have  never 
menstruated  normally,  it  is  well  to  make  a  careful 
examination,  and  be  sure  that  there  is  no  obstruction  to 
the  flow  of  blood  from  the  uterus.  If  for  a  number  of 
successive  months  the  blood  comes  from  the  lungs,  there 
is  reason  to  fear  tuberculosis  will  follow,  especially  in 
scrofulous  women,  or  those  having  an  hereditary  taint. 

1  This  case  was  cured  by  Pulsatilla. 


184  VICARIOUS  MENSTRUATION. 

The  general  treatment  of  vicarious  menstruation  is 
just  the  same  as  for  amenorrhoea,  to  which  the  reader 
is  referred.  The  importance  of  constitutional  remedies 
and  treatment  must  never  be  overlooked. 

THERAPEUTICS. 

II  Bryonia.  Besides  other  symptoms  which  may  be  present, 
it  is  applicable  for  vicarious  menstruation  in  the  form  of  epis- 
taxis ;  also,  for  suppression  of  the  menses  with  epistaxis  (Carls- 
bad water,  ham.,  puis.,  sepia)  in  women  accustomed  to  too 
early  and  too  profuse  menstruation  (Calc.  carb.).  The  blood 
is  florid,  and  the  bleeding  is  most  often  in  the  morning,  some- 
times waking  the  patient  from  sleep.  While  bryonia  is  especially 
apphcable  to  the  above,  it  should  not  be  forgotten  in  other 
forms  of  this  affection,  as  clinical  experience  shows  it  is  one  of 
the  chief  remedies. 

Ferrum.  Dr.  Leadam's  favorite  remedy;  anaemic  women 
subject  to  fiery  red  flushing  of  the  face ;  suppression  of  the 
menses  with  haemoptysis  (Dig.,  millefolium,  phos.). 

I  Hamamelis.  Vicarious  menstruation  of  dark  or  venous 
blood  from  the  nose,  mouth,  stomach,  or  hemorrhoids.  The 
presence  of  varicose  veins,  and  a  fluid  rather  than  clotted  con- 
dition of  the  blood,  are  additional  indications. 

I  Pulsatilla.  Epistaxis,  haematemesis,  or  expectoration  of 
pieces  of  dark  coagulated  blood,  with  suppression  of  the  menses. 
The  pressive  throbbing  headache,  palpitation,  chilHness,  and 
the  above  symptoms,  with  scanty  or  delayed  menstruation,  are 
additional  indications  for  this  remedy.  Dr.  Kapper '  reports  an 
interesting  case  cured  in  six  weeks  by  this  remedy.  The  prin- 
cipal symptoms  were,  violent  headache,  dazzling  before  the 
eyes,  twitches  in  the  nose,  tightness  of  the  chest,  fulness  of 
the  mammae,  and  oppression  of  the  stomach,  followed  by  violent 
epistaxis  and  flow  of  blood  from  the  breasts,  with  rehef  and 
cessation  of  all  the  symptoms.  This  had  been  repeated  a  num- 
ber of  successive  months.    The  girl  was  apparently  well,  eighteen 

*  Zeitsch.  f.  Horn.  Klinik,  vol.  i.  p.  106. 


THERAPEUTICS.  185 

years  old,  and  had  never  normally  menstruated ;  warm  sitz- 
baths,  leeches,  and  purgatives  had  been  tried  without  any 
benefit. 

The  following  remedies  are  less  frequently  useful :  — 
Alumina,  dell,  calc.  carb.,  calc.  phos.,  Carlsbad  water, 

digitalis,'  kali  carb.,  lach.,  lycopodium,^  natr.  mur.,  phos., 

sang.,  senecio,^  sepia,  sulph.,  veratr.  alb. 

'  Dr.  W.  H.  Hoyt  reports  a  case  cured  by  digitalis,  characterized  by  tlie  follow- 
ing symptoms :  pain  in  and  about  the  chest,  and  sometimes  epistaxis  before  the 
menses,  followed  by  choking  spasmodic  cough  at  night,  and  the  expectoration  of  a 
solid,  bloody  mass  of  mucus  with  immediate  relief.  This  mucus  was  very  diffi- 
cult to  detach,  and  often  presented  a  rusty,  black,  and  clot-like  appearance.  — 
Transactio7is  N.  Y.  State  Soc.,  1869,  P-  3°9- 

^  Dr.  Leadam  reports  a  case  cured  by  lycopodium.  The  patient  was  subject  to 
very  irregular  menstruation  ;  in  the  intervals,  first  serum  and  then  blood  oozed  out 
of  the  right  nipple.  —  Leadam  :  Diseases  of  Woi/ien,  1874,  p.  33. 

3  The  menses  appeared  at  the  age  of  fourteen ;  she  was  regular  till  sixteen  ; 
since  then  for  three  years  the  menstruation  has  entirely  ceased,  and  instead  she  has 
hemoptysis,  spitting  blood  for  one  day  during  every  month.  Pulsatilla  ix.  three 
times  a  day  was  given  for  twenty  days  ;  it  was  then  five  weeks  since  she  last  spit 
blood,  but  the  menses  did  not  appear ;  she  then  received  senecio  ix.  two  drops 
three  tirries  a  day,  and  the  flow  appeared  on  the  tenth  day  after  using  senecio.  — 
Dr.  Harmar  Smith,  Hotii.  World,  p.  537,  Dec.  i,  1882.  (Though  not  posi- 
tively stated,  it  is  inferred  that  the  case  was  permanently  cured,  or  it  would  not 
have  been  reported  as  a  case  of  vicarious  menstruation  cured  by  senecio.) 


1 86  D  YSMENORRHCEA . 


CHAPTER    XIV. 

DYSMENORRHCEA,  OR    PAINFUL   MENSTRUATION. 

LIKE  leucorrhoea,  this  is  not  a  disease  in  itself,  but 
a  symptom  ;  i.e.,  it  is  secondary  to  some  primary 
affection.  It  has  been  classified,  for  convenience  of  de- 
scription, as  neuralgic,  ovarian,  congestive,  obstructive, 
and-  membranous  dysmenorrhoea ;  but  these  forms  so 
often  overlap  each  other,  that  frequently  a  case  cannot 
be  positively  assigned  to  any  one  of  them.  The  pathol- 
ology  is  not  well  understood,  and  eminent  physicians 
have  very  different  opinions  concerning  it.  Fortu- 
nately, this  does  not  interfere  with  the  successful  treat- 
ment of  a  large  majority  of  these  cases. 

It  would  seem  that  hyperaesthesia  of  the  nerves,  or 
perturbation  of  nerve-force  in  and  about  the  uterus, 
plays  an  important  rS/e  in  nearly  all  cases  of  dysmen- 
orrhoea. The  same  causes  producing  neuralgia  in  other 
parts  of  the  body  produce  a  similar  condition  in  the 
pelvic  organs.'  In  other  cases,  the  hyperaesthesia  may 
be  caused  by  the  inflamed  or  engorged  ovary  or  uterus, 
which  is  relieved  by  the  escape  of  the  menstrual  blood. 
This  is  not  unlike  the  pain  of  any  localized  inflamma- 
tion, such  as  a  whitlow,  which  is  relieved  by  lancing, 
and  the  escape  of  blood. 

The  theory  of  obstruction  to  the  escape  of  the  men- 
strual flow,   as  a  cause  of  painful   menstruation,   will 

'  Austie  :  Neuralgia,  and  the  Diseases  that  produce  it,  p.  69. 


ETIOLOGY  OF  DYSMENORRHCEA.  187 

hardly  account  for  so  large  a  proportion  of  cases  as 
some  authors  have  thought.  How  many  times  physi- 
cians observe  patients  having  a  pin-hole  os,  or  an 
extremely  small  cervical  canal,  who  do  not  suffer  much 
during  the  menstrual  period  ;  while  others,  having  a 
much  larger  canal,  are  in  agony  at  such  times. 

The  cervical  canal  may  be  large  enough  in  uterine 
flexions;  but  the  bending  of  the  cervix  on  the  body  of 
the  uterus  will  more  or  less  occlude  its  canal,  the  calibre 
of  its  blood-vessels  become  altered,  and  a  varying  degree 
of  engorgement  of  the  blood-vessels  results.  The  con- 
ditions are  then  similar  to  the  preceding  form.  It  is 
noticeable,  that,  when  the  site  of  flexion  is  above  the 
vaginal  junction,  the  dysmenorrhoea  is  more  often  severe, 
and  not  always  relieved  by  enlarging  the  canal  by  in- 
cision. When  the  flexion  is  below  the  vaginal  junction, 
or  the  contraction  at  the  external  os,  i.e.,  where  the 
circulation  is  not  disturbed,  dysmenorrhoea  is  rare. 

The  pain  caused  by  the  mechanical  dilatation  of  the 
uterus,  and  subsequent  contraction  to  expel  its  con- 
tents, which  have  accumulated  in  consequence  of  a 
spasmodic  stricture  at  the  internal  os,  occlusion  of  the 
canal  by  a  polypus,  or  from  any  other  cause,  cannot  be 
ascribed  to  a  nervous  origin. 

Another  argument  in  favor  of  nervous  irritability  or 
hyperaesthesia,  as  the  cause  of  painful  menstruation, 
is,  that  the  most  effectual  medicines  in  its  treatment 
are  among  the  best  for  the  treatment  of  nervous  dis- 
orders in  other  parts  of  the  body.  The  dilatation  of 
the  inferior  segment  of  the  uterus,  by  parturition  or 
instruments,  can  be  compared  to  nerve-stretching  for 
neuralgia,  or  dilatation  of  the  urethra  for  cystalgia. 

There  is  little  positively  known  concerning  the 
etiology  or  pathology  of  membranous  dysmenorrhoea. 
It  must  be  accepted,  however,  as  a  clinical  fact,  that 


1 8  8  D  YSMENORRHCEA . 

apparent  shreds  of  membrane,  or  casts  of  the  uterine 
cavity,  are  expelled  with  great  pain,  and  that  this  form 
of  membranous  dysmenorrhoea  is  often  exceedingly  diffi- 
cult to  cure. 

The  varieties  of  painful  menstruation  mentioned  are 
convenient  for  purposes  of  description,  and  are  there- 
fore sfiven  in  the  following  table  :  — 


Form. 

Neuralgic 
dysmenor- 
rhcea. 


Etiology. 


Ovarian. 


Congestive. 


Symptoms. 


Patients  subject  to 
rheumatism  or  neuralgia. 
Any  thing  which  de- 
presses the  system,  or 
enervating  habits  leading 
to  neuralgia  in  other 
parts  of  the  body,  may 
cause  it  here.  Laceration 
of  the  cervix  uteri. 

The  same  as  for  chronic 
ovaritis.  Particularly,  re- 
peated and  severe  cauter- 
ization of  the  cervix  with 
nitrate  of  silver. 


Inflammation  in  or 
about  the  uterus;  dis- 
placement of  the  latter; 
any  cause  producing  con- 
gestion, such  as  the  pres- 
ence of  a  fibroid  tumor 
or  polypus ;  slow  circula- 
tion in  the  portal  vein; 
mental  shock ;  the  action 
of  cold  and  wet,  espe- 
cially at  the  time  of  the 
menses,  or  in  plethoric 
women.  The  latter  is  a 
very  common  cause  of 
congestive  dysmenor- 
rhoea in  girls,  while  uter- 
ine displacement  is  a 
more  frequent  one  in 
later  life. 


Prognosis. 


The  pain  is  of  a  sharp, 
fixed  character,  usually 
local,  and,  less  often,  in 
distant  parts  of  the  body. 
It  varies  in  intensity,  some- 
times appears  before  the 
flow,  and  may  stop  with, 
or  continue  during,  the  dis- 
charge. 

There  is  often  pain  at  in- 
tervals between  the  menses ; 
it  commences  a  few  days 
before  the  flow,  and  dimin- 
ishes with  it.  The  pain  is 
dull,  aching,  and  often  ac- 
companied by  depression 
of  spirits,  nervous  phenom- 
ena, and  sympathetic  dis- 
turbances in  the  breasts. 

Severe  pain  comes  on 
suddenly  during  the  period, 
with  a  decrease  or  arrest  of 
the  flow,  and  considerable 
fever  in  proportion  to  the 
amount  of  congestion  or 
inflammation. 


If  the  patient  has 
not  been  subject  to 
neuralgia  for  a  long 
time,  and  can  be  built 
up  to  a  high  standard 
of  health,  recovery  is 
probable  ;  otherwise 
it  is  doubtful. 

Unless  the  case  is  a 
recent  one,  recovery 
is  improbable,  espe- 
cially so  if  the  ovar- 
itis followed  cauteri- 
zation of  the  cervix 
with  nitrate  of  silver. 
Sterility  is  common. 


Good  if  the  cause 
can  be  removed. 


FORMS   OF  DYSMENORRHCEA. 


189 


Form. 


Obstructive. 


Etiology. 


Membran- 
ous. 


Congenitally  small  cer- 
vical canal,  or  contrac- 
tion of  the  latter  after  the 
application  to  it  of  strong 
caustics;  bending  of  the 
canal  on  itself,  as  in  retro- 
flexion; a  polypus  or 
fibroid  in  the  cervix,  en- 
croaching on  iis  canal; 
occlusion  of  any  portion 
of  the  vagina  ;  endo- 
metr  tis  is  almost  always 
present  in  consequence 
of  the  pent-up  fluids  in 
the  uterine  cavity. 


By  some  means,  the 
lining  membrane  of  the 
uterine  cavity  is  cast  off 
either  entire  or  in  pieces. 
The  true  causes  of  this 
affection  are  not  known. 
It  would  seem  as  if  it 
might  be  called  a  variety 
of  endometritis.' 


Symptoms. 


The  usual  menstrual 
symptoms  appear,  but  with 
very  little,  if  any,  discharge 
of  blood.  The  latter  gradu- 
ally collects  in  a  few  hours, 
and  distends  the  uterus. 
Spasmodic,  labor-like  pains 
are  excited  till  the  uterine 
contractions  overcome  the 
obstruction,  and  there  is  a 
gush  of  the  imprisoned 
blood,  with  one  or  two 
clots,  which  relieves  the 
pain.  In  some  cases  of 
marked  obstruction,  the 
process  is  repeated  till  men- 
struation ceases. 

Pain  commences  with  the 
flow,  gradually  increases 
in  severity,  and  becomes 
labor-like,  till  the  mem- 
brane is  discharged,  and 
then  ceases.  The  flow  is 
then  more  profuse,  and  is 
followed  by  a  variable 
amount  of  leucorrhoea. 


Prognosis. 

Good  in  the  great 
majority  of  cases. 


As  a  rule,  unfavor- 
able. 


'  Fibrinous  endometritis  forms  a  complete  cast,  very  similar  to  that  of  mem- 
branous dysmenorrhoea.  The  outer  surface  of  the  former  is  smooth,  and  the  cast 
usually  solid,  while  the  surface  of  the  latter  is  rough  and  papillary,  and  the  cast  is 
hollow,  i.e.,  it  forms  a  sac  with  three  openings.  A  microscopic  examination  will 
readily  show  the  difference  (compare  Orth.  Diagnosis  Path.  A7iat.,  p.  255). 

'  Dr.  Kleinwaechter  in  the  Wiener  Kliiiik,  February,  18S5,  quoted  in  A7n. 
Jour,  of  Obstetrics,  p.  1115,  1885,  terms  it  exfoliative  endometritis.  Dr.  Alexan- 
der J.  C.  Skene  agrees  with  him  that  the  membrane  is  an  exfoliation  in  mass  of  the 
mucous  membrane  of  the  uterus  at  the  menstrual  period.  —  N.  Y.  Med.  Journal, 
December,  i88s. 


IQO 


D  YSMENORRHCEA . 


DIFFERENTIAL    DIAGNOSIS. 


Neuralgic. 

Ovarian. 

Obstructive . 

Congestive. 

Membrano7is. 

Pain    not    ex- 

Pain    c  0  m- 

Pain      expul- 

Pain   comes 

The  discharge  of 

pulsive. 

mences       some 

sive,  labor-like. 

suddenly  during 

the    membrane    is 

days  before  the 

finally   followed 

the  period. 

sufficient  to  distin- 

flow,  and    does 

by  discharge  of 

guish  it.     It  is  rec- 

not affect  it. 

blood  and  clots, 
which     relieves 
the  pain. 

ognized  from  blood 
clots,  fibrin  casts, 
or  early  abortions, 
by    the    discharge 
of  only  one  mem- 
brane   during    the 
period,  its  charac- 
teristic     elements 
under    the    micro- 
scope, and  its  recur- 
rence each  month. 

No     constitu- 

No    constitu- 

Constitutional 

Constitutional 

tional       disturb- 

tional    disturb- 

disturbance 

disturbance, 

ance,     such     as 

ance,     such     as 

slight. 

headache, 

fever  or  inflam- 

fever or  inflam- 

flushed face,  and 

mation. 

mation. 

fever,  in  propor- 
tion to  severity 
of  congestion  or 
inflammation. 

Flow    steady ; 

Flow  steady; 

Flow  usually 

Flow     dimin- 

develops  gradu- 

dates   from    an 

interrupted  ; 

ished,  or  arrest- 

ally, and  is  ha- 

attack  of  ovar- 

may be  congen- 

ed  ;     comes   on 

bitual. 

itis,  or  exposure 

ital,  or  have 

suddenly,     dur- 

during menstru- 

slowly   d  e  V  e  1- 

ing  a  period,  in 

ation. 

oped. 

women      accus- 
tomed  to  pain- 
less    menstrua- 
tion, and  is  not 
habitual. 

Examination 

One   or   both 

Examination 

Examination 

reveals  no  phys- 

ovaries are  usu- 

with   finger    or 

reveals   conges- 

ical    cause     for 

ally    enlarged 

probe    during 

tion,  or  a  vary- 

pain. 

and      inflamed ; 

menstruation 

ing   amount  of 

nervous     symp- 

shows    an     ob- 

inflammation in 

toms   and   sym- 

struction to  the 

or     about      the 

pathetic     irrita- 

flow. 

uterus. 

tion    of    the 

breasts;  nausea 

and  vomiting. 

TREATMENT  OF  DYSMENORRHOEA.  191 

The  successful  treatment  of  dysmenorrhcea  depends 
very  largely  upon  the  removal  of  the  cause.  In  most 
cases  an  examination  is  necessary,  in  order  to  treat  the 
patient  intelligently.  In  young  unmarried  women,  or 
girls,  the  advisability  of  it  may  be  questioned.  When, 
however,  pain  continues  to  a  marked  degree,  through- 
out the  period,  and  is  repeated  from  month  to  month, 
in  spite  of  carefully  selected  remedies,  an  examination 
must  be  made.  In  young  girls,  enough  information  can 
often  be  obtained  through  the  rectum,  instead  of  the 
vagina,  i.e.,  a  displacement  of  the  uterus,  cellulitis,  or 
ovarij;is ;  but  if  an  examination  per  vaginam  is  neces- 
sary after  this,  ether  should  be  used.  It  is  an  important 
fact,  as  Dr.  Emmet  has  shown,  that,  of  all  married 
women  who  had  dysmenorrhcea  in  early  life,  71.90  per 
cent  were  sterile.  It  is  a  false  delicacy  which  allows 
diseases  and  consequent  suffering  to  become  estab- 
lished, which  might  have  been  cured  at  their  com- 
mencement. 

In  some  cases  marriage  has  a  very  beneficial  effect, 
especially  if  followed  by  parturition. 

It  is  quite  unnecessary  here  to  go  into  the  details  of 
the  treatment  of  inflammation  in  or  about  the  uterus, 
of  displacements,  or  other  causes  which  will  be  found 
elsewhere  in  this  book.  Although  many  authors  admit 
they  are  forced,  at  times,  to  use  suppositories  of  mor- 
phia and  belladonna,  all  unite  in  condemning  the  use 
of  anodynes  as  a  most  pernicious  practice. 

Neuralgic  Dysmenorrhcea  should  receive  the  same  gen- 
eral treatment  as  neuralgia  occurring  in  other  parts  of 
the  body.  Not  only  is  a  nourishing,  generous  diet  im- 
portant, but  often  a  change  of  air,  out-door  exercise, 
or  a  sea-voyage  is  very  beneficial.  The  passage  of  a 
large  sound  through  the  cervical  canal,  the  day  before 
the  expected  monthly,  may  entirely  relieve  the  patient 


1 92  D  YSMENORRHCEA . 

from  pain  ;  and  if  this  fails,  rapid  dilatation  '  is  advis- 
able, provide  dremedies  are  ineffectual.  Electricity  in 
this,  as  in  the  following  form,  will  sometimes  promptly 
relieve  the  patient. 

Ovarian  Dysmenorrhoea  is  very  stubborn  to  treat,  and 
likely  to  be  attended  by  sterility.  The  only  local  treat- 
ment advisable  is  that  used  for  ovaritis,  such  as  hot 
sitz-baths,  and  soothing  vaginal  injections.  Unless 
complicated  with  some  of  the  other  forms,  dilatation  of 
the  cervical  canal  would  probably  be  useless. 

Under  this  head  may  be  mentioned  a  form  of  scanty 
and  painful  menstruation  in  young  women  or  girls,  in 
which  there  is  a  marked  tendency  to  amenorrhoea,  or  pro- 
gressively diminishing  menstrual  flow.  This  seems  due 
to  non-development  of  the  ovaries,  and  tends  to  atrophy 
of  them  ending  in  sterility,  or  immature  development  of 
the  genital  organs.  Here,  again,  nutrition  of  the  system, 
rest  from  mental  work,  outdoor  air,  and  exercise  are  of 
prime  importance,  and  may  alone  suffice.  This  will  be 
shown  by  the  increase  of  the  menstrual  flow,  and  pro- 
portionate decrease  of  pain.  Besides  the  removal  of 
any  focus  of  irritation  in  the  pelvis,  Dr.  Emmet  rec- 
ommends the  use  of  a  small  sponge-tent,  immediately 
before  the  expected  period,  to  bring  on  the  flow.  Elec- 
tricity has  sometimes  proved  useful,  by  passing  a  Faradic 
current  between  the  hypogastric  and  sacral  or  lumbar 
regions,  the  electrodes  being  placed  externally ;  or  by 
wearing  the  intra-uterine  galvanic  stem  pessary,  com- 
posed of  alternate  layers  of  zinc  and  copper  plates. 

Congestive  Dysnienorrhcea  is  much  more  susceptible  to 
treatment.  Any  deviation  of  the  uterus,  from  its  nor- 
mal position,  must  be  corrected  ;  and  if  the  flow  has 
been  suppressed  by  exposure  to  cold  or  wet,  measures 

'  See  chapter  on  Minor  Surgical  Gynaecology. 


TREATMENT   OF  DYS MENORRIICEA.  193 

must  be  taken  at  once  to  bring  it  on.  The  best  way  to 
do  this  is  to  have  the  patient  prepare  for  bed,  and,  sit- 
ting on  the  edge  of  the  latter,  soak  her  feet  in  hot  water 
and  mustard,  with  blankets  well  wrapped  around  her 
till  the  skin  begins  to  perspire.  The  action  of  the  skin 
may  be  hastened  by  drinking  hot  weak  tea,  or  hot  water 
with  a  little  essence  of  ginger,  while  the  temperature  of 
the  foot-bath  is  increased  gradually  by  the  addition  of  a 
little  more  hot  water.  A  bottle  of  gin  is  very  often 
kept  in  the  house  as  a  remedy  for  scanty  or  suppressed 
menses.  When  perspiration  commences,  the  patient 
lifts  her  feet  out  of  the  water,  keeping  them  in  the 
blankets,  without  stopping  to  wipe  them,  and  lies  back 
in  bed.  This,  with  proper  medicines,  is  usually  suffi- 
cient, unless  some  few  days  have  elapsed,  when  it  is  of 
little  use  to  try  it  before  the  time  of  the  next  period. 
In  the  interval  between,  copious  hot-water  vaginal 
douches,  with  an  occasional  application  of  glycerine,  are 
useful  to  allay  the  tendency  to  passive  congestion. 

The  injurious  effects  of  tight  lacing,  and  heavy 
dresses  suspended  from  the  waist,  in  obstructing  free 
circulation  in  the  abdominal  veins,  must  not  be  over- 
looked. The  weight  of  the  dresses  should  come  on  the 
shoulders,  by  buttoning  the  garments  on  a  waist  or 
skirt-supporter;  while,  if  it  is  a  rule  to  have  the  corsets 
fit  loose  enough  to  easily  pass  the  hand  up  beneath 
them  after  lacing,  little  harm  can  be  done. 

Chapman's  spinal  ice-bags  are  sometimes  very  useful 
for  dysmenorrhoea,  with  scanty  and  tardy  discharge. 
Use  one  for  half  an  hour,  once  or  twice  a  day,  when  the 
pain  comes. 

Obstructive  Dysmenorrhoea,  of  all  the  forms,  is  the 
most  difficult  to  cure  by  any  other  than  local  treatment. 
Medicines  are  of  little  avail  till  after  the  exciting  cause 
has  been   removed,  and  then  seldom   necessary.     The 


194  "  DYSMENORRHOEA. 

removal  of  a  small  fibroid  or  polypus,  the  straightening 
of  the  uterus,  or  dilatation  of  its  canal,'  is  followed  by 
very  marked  and  prompt  improvement  or  cure.  As  a 
rule,  dilatation  is  the  most  effectual,  and  is  superseding 
the  treatment  of  incising  the  cervix,  in  cases  of  flexion, 
which  was  so  ably  advocated  by  Simpson  and  Sims.^- 
One  great  reason  for  this  is  the  slight  amount  of  risk 
involved.  It  must,  as  a  rule,  be  thorough  to  be  effectual, 
and  followed  by  the  occasional  use  of  an  intra-uterine 
stem,  of  glass  or  hard  rubber,  to  prevent  a  possible 
contraction  of  the  canal. 

Membranous  DysDienorrJicea  is,  of  all  forms,  the  most 
difificult  to  cure.  Local  treatment,  except  as  it  may 
relieve  various  complications,  is  of  no  use.  Dilatation 
of  the  cervix,  just  before  the  period,  has  been  tried,  to 
facilitate  the  extrusion  of  the  membrane;  but  this,  like 
anodynes,  is  often  merely  palliative,  except  as  it  allows 
the  blood  to  escape  more  freely,  relieves  congestion,  and, 
in  turn,  may  possibly  avert  the  tendency  to  hyperplasia 
of  the  lining  membrane  of  the  uterine  cavity.  It  'is 
possible  that  the  intra-uterine  application  of  the  nega- 
tive pole  of  the  galvanic  current  flight  have  an  altera- 
tive effect  on  nutrition,  and  thus  prove  beneficial.  The 
current,  however,  must  be  very  weak. 

TJie  Medical  Treatment  of  dysmenorrhoea,  excepting 
the  obstructive  and  membranous  varieties,  is  usually 
quite  satisfactory.  In  the  dominant  school,  the  valerian- 
ate of  ammonia  has  quite  a  reputation  for  dysmenorrhoea 
in  hysterical  young  women,  but  it  is  merely  palliative. 
Not  infrequently  one  remedy  must  be  given  between 
the  periods,  and  another  at  the  time  to  relieve  the  pain. 
The  clinical  value  of  the  remedies  is  very  much  in- 
jured,- however,  when  more   than   one  is  used.      As  a 

'  See  chap.  ii. 

^  See  Notes  on  Uterine  Surgery,  by  Marion  Sims,  M.D. 


THERAPEUTICS   OE  DYSMENORRHGZA .       IQS 

rule,  the  intercurrent  remedy  sliould  be  directed  to  the 
cause  of  the  dysmenorrhoea;  whatever  that  may  be, 
its  removal  is  absolutely  essential  to  a  permanent  cure. 

THERAPEUTICS. 

Aconite.'  Congestive  dysmenorrhoea,  in  conseriuence  of 
suppression  of  the  menses,  especially  if  from  fright  (Lye.)  or 
vexation,  in  plethoric  women,  accustomed  to  profuse  flowing. 
Ovaritis  may  be  present.  The  pain  is  sharp  and  cutting ;  the 
vagina  hot,  dry,  and  sensitive  (Bell.),  with  painful  urging  to 
urinate.  The  patient  is  very  restless,  and  tosses  about ;  thirsty, 
and  the  pulse  full,  hard,  and  strong. 

Ammonium  Carb.  Recommended  by  Dr.  I.  T.  Talbot ' 
for  dysmenorrhoea  in  persons  of  nervous,  sanguine  tempera- 
ment, when  the  pain  is  cramp-like,  confined  to  the  uterine 
region,  and  occurring,  for  the  most  part,  before  the  flow,  with 
pallor  of  the  countenance.  The  flow  is  blackish  or  clotted, 
too  early  and  abundant.  The  acetate  is  preferred  by  some 
physicians.  Dr.  H.  H.  Read  found  this  remedy  not  only  cured 
the  dysmenorrhoea,  but  also  had  an  excellent  effect  on  the 
general  health  of  a  patient  who  suffered  from  cramps  and 
diarrhoea  coming  three  or  four  days  in  advance  of  the  men- 
strual flow.  Several  remedies  had  been  given  previously,  with- 
out any  relief. 

Belladonna.  Atropine  is  sometimes  used  instead.  Dr. 
Dunham  3  found  it  a  very  effective  remedy  for  the  following 
symptoms  :  Very  severe  pain,  dragging,  and  pressing-down  in 

^  Girl  set.  22.  Strong  and  plethoric.  Has  always  had  severe,  agonizing  d3-s- 
menorrhoea.  Violent  cutting  pains  in  the  back  and  loins,  like  labor  pains,  for  the 
first  two  days.  On  the  third  day,  violent  cutting  pains  in  the  abdomen.  On 
the  last  day,  very  severe  pressive  headache.  Menses  every  three  weeks,  discharge 
copious  and  dark.  Bell,  helped  the  backache,  puis,  the  abdominal  pains,  ignatia 
the  headache  ;  but  they  only  proved  palliative.  Suspecting  inflammatory  irritation 
as  the  cause,  I  gave  aconite  6.  The  pain  soon  ceased.  She  had  two  doses  of  aconite 
the  next  month.  The  flow  then  became  regular  every  four  weeks,  and  painless. 
This  was  thirteen  years  ago,  and  she  has  had  no  return  of  it  in  that  time.  — 
Dr.  Elb.  Zeitsch,  y.  Horn.  Klinik,  vol.  i.  p.  4. 

^  New-England  Med.  Gazette,  vol.  iv.  p.  56,  1S69. 

3  Lectures  on  Mat.  Med.,  vol.  i.  p.  262,  1878. 


1 96  D  YSMENORRHOEA . 

the  pelvis ;  also  cutting  pains  through  the  pelvis,  i.e.,  hori- 
zontally, not  around  it  like  sepia  and  platina.  These  pains  are 
paroxysmal,  and  precede  the  menstrual  period  from  six  to 
twenty-four  hours.  The  ovary,  more  often  the  right,  is  inflamed 
and  prolapsed,  making  defecation  painful  at  this  time.  It 
should  be  given  just  before  the  menstrual  epoch,  and,  if  neces- 
sary, be  persisted  w^ith  for  many  consecutive  months. 

It  is  also  useful  for  sudden  suppression  of  the  menses  from 
cold,  with  severe  bearing-down  pain  and  throbbing  in  the  hypo- 
gastric region;  flushed  face,  throbbing  headache,  and  difficult 
or  painful  micturition. 

Borax.  The  action  of  this  remedy  on  the  uterus  is  not 
thoroughly  understood.  It  has  been  successfully  used  for  mem- 
branous dysmenorrhcea,'  but  is  by  no  means  a  specific  for  it. 
The  best  results  from  it  have  been  obtained  from  the  pure 
substance  in  from  three  to  five  grain  doses.  This  use  of  the 
remedy  is  said  to  have  originated  with  Dr.  Henry  Bennet.  Dr. 
Guernsey  gives  "  fear  of  downward  motion  "  as  a  great  character- 
istic of  this  drug.  Dysmenorrhoea  with  sterility.^  The  menses 
are  too  early  and  profuse,  with  nausea  and  colic ;  leucorrhoea 
like  the  white  of  egg  (Amm.  mur.,  bovista,  calc.  phos.,  mez.), 
with  sensation  as  if  warm  water  were  flo7ving  down.  It 
may  be  chronic  and  acrid,  accompanying  sterility  with  great 
nervousness. 

I  Caulophyllin.  Spasmodic  pains  in  the  uterus  and  vari- 
ous parts  of  hypogastriuni.  The  flow  is  either  normal  or  scanty, 
in  patients  subject  to  rheumatism  of  the  small  joints.  It  is 
also  useful  for  moth-spots  on  the  face  in  women  subject  to 
menstrual  irregularities  or  leucorrhcea  (Sepia).     Dr.  D.  Dyce 


'  Dr.  A.  H.  Tompkins,  New-Eng.  Med.  Gazette,  December,  1879.  Two  cases 
of  membranous  dysmenorrhoea  cured,  one  with  five-grain  doses  of  the  crude  drug  ; 
the  other,  with  2x.  trit. 

'  Transactions  N.  Y.  State  Horn.  Soc,  vol.  x.  p.  279.  The  first  attenuation 
was  used. 

1  Case  of  radical  cure  reported  by  Dr.  E.  M.  Hale,  Brit.  Journal  of  Horn., 
vol.  xxix.  p.  748,  1 871.  In  this  case  pure  borax  was  given,  in  five-grain  doses, 
three  times  a  day. 

2  Hahn.  Monthly,  March,  iSSo. 


THERAPEUTICS  OE  DYSMENORRHOLA.       197 

Brown  thinks  highly  of  it,  both  at  the  time  of  the  pain  and 
between  the  periods. 

I  Chamomilla.  Neuralgic  dysmenorrhoea  (Coffea).  The 
flow  is  too  early,  too  profuse,  and  offensive  (Bell.)  ;  drawing 
pain  from  sacral  region  forward ;  griping,  pinching,  labor-like 
pains  in  the  uterits,  followed  by  the  discharge  of  large  clots  of 
blood ;  the  patient  is  impatient,  irritable,  and  very  sensitive  to 
pain. 

I  Cimicifuga.  Macrotin,  an  impure  resin  (not  the  active 
principle),  obtained  from  the  tincture,  is  preferred  by  many 
practitioners.  Rheumatic  dysmenorrhea,  i.e.,  dysmenorrhoea  in 
patients  subject  to  muscular  rheumatism,  and  an  apparent  metas- 
tasis to  the  uterus,  which  is  irritable,  and  feels  sore  or  bruised 
on  examination.  (Dr.  Dewees,  in  the  old  school,  introduced 
guiac.  as  a  remedy  for  this  condition.)  Menses  irregular,  de- 
layed, or  suppressed  ;  hysterical  or  epileptic  spasms  at  the  time 
of  the  menses ;  pains  in  ovarian  region  shoot  upward,  in  uterine 
region,  from  side  to  side  ;  bearing-down  and  tenderness  in  the 
hypogastric  region  ;  limbs  feel  heavy. 

I  Cocculus.  Dr.  Edward  Blake  considers  this  the  best 
remedy  for  dysmenorrhoea,  as  well  as  menstrual  colic  from 
flatulence  generated  by  the  intestinal  walls,  more  often  at  night, 
and  especially  during  menstruation  and  pregnancy.  Menses 
too  early,  with  cramps  in  the  abdomen,  and  colic  pains ;  great 
weakness  during  the  menses  (Amm.  carb.,  carb.  an.),  severe 
headache  on  third  or  fourth  day  of  the  flow ;  light  and  noise 
intolerable,  and  accompanied  by  nausea,  like  the  heaving  up 
and  down  of  the  stomach  in  sea-sickness ;  sudden  cessation  of 
the  flow,  followed  by  severe  spasmodic  pains ;  dysmenorrhoea 
in  girls  and  childless  women ;  flow  may  be  scanty,  or  very  pro- 
fuse, with  pain  in  the  breasts,  restlessness,  groaning,  vomiting ; 
small  pulse,  and  great .  weakness ;  leucorrhcea  between  the 
periods.  Dr.  Lobeth  praised  it  as  a  remedy  between  the 
monthlies,  but  did  not  value  it  as  highly  during  the  monthly 
epoch.  Dr.  Hartman  esteemed  it  very  highly ;  but  in  extremely 
severe  cases,  when  the  attacks  resembled  epilepsy,  he  used 
cuprum  met.  instead. 


198-  D  YSMENORRHCEA . 

Collinsonia  is  a  good  remedy,  especially  between  the 
periods,  for  dysmenorrhoea  associated  with  passive  congestion 
of  the  uterus,  hemorrhoids,  and  constipation. 

Colocynth.  Severe  left-sided  ovarian  dysmenorrhoea,  caus- 
ing the  patient  to  double  up  ;  colicky  pain  two  or  three  days 
before  the  menses,  extending  below  the  navel  to  the  genitals, 
relieved  by  warmth,  and  associated  with  cold  feet.  The  pains 
are  also  relieved  by  flexing  the  thigh  on  the  abdomen. 

I  Gelsemium  ix.  is  best  given  in  hot  water,  a  teaspoonful 
every  fifteen  minutes,  and  less  often  as  soon  as  there  is  any 
improvement,  which  will  be  sure  to  follow,  if  at  all,  after  three  or 
four  doses  are  taken,  provided  the  remedy  was  administered  as 
soon  as  the  pain  commenced.  It  is  one  of  the  very  best  remedies 
for  spasmodic  dysmenorrhoea  ;  but,  as  a  rule,  some  other  remedy, 
such  as  caulophyllum,  is  required  between  the  menstrual  periods 
to  effect  a  cure.  Severe,  sharp,  labor-like  pains  in  the  uterine 
region,  extending  to  the  back  and  hips  (Cimicif.,  secale  cor.)  ; 
dysmenorrhoea,  preceded  by  sick  headache,  vomiting ;  conges- 
tion to  the  head  ;  confused  vision ;  deep  red  face ;  bearing- 
down  in  the  abdomen ;  the  patient  passes  large  quantities  of 
limpid,  clear  urine,  which  relieves  the  headache.  It  is  esteemed 
very  highly  by  Dr.  D.  Dyce  Brown. ^ 

Hamamelis  has  been  praised  as  a  remedy  for  ovarian 
dysmenorrhoea.  There  is  severe  pain  through  the  lumbar  and 
hypogastric  regions,  and  down  the  legs ;  the  ovaries  are  sore 
and  painful,  the  veins  distended,  and  the  flow  profuse. 

Pulsatilla  is  an  excellent  remedy  for  dysmenorrhoea,  given 
between  the  periods,  rather  than  at  the  time  of  pain,  when  some 
other  medicine  is  often  more  applicable.  It  is  particularly  use- 
ful for  suppression  of  the  menses  from  wetting  the  feet,  and  is 
always  to  be  remembered  with  aconite  in  congestive  dysmenor- 
rhoea from  this  cause  ;  also  for  delayed,  scanty,  and  painful 
menstruation.  The  pain  is  constrictive,  labor-like,  more  often 
in  the  left  side  of  the  uterus,  and  obliges  the  patient  to  bend 

'  He  recommends  ^sA.,  cauloph.,  xanthox.,  cimicif.,  cocc,  ciipr.,  and  ignatia, 
in  his  lecture  on  the  Diseases  of  Women,  at  the  London  School  of  Homoeopathy. 
—  Monthly  Horn.  Reviezv,  p.  46^,  Aug.  i,  1881. 


THERAPEUTICS  OE ,  DYSMENORRHCEA.       199 

double.  In  aconite,  the  discharge  is  bright  red,  and  the  patient 
inclined  to  plethora.  In  pulsatilla,  the  discharge  is  dark  and 
clotted,  and  the  patient  of  a  lymphatic  temperament. 

Senecia.'  Painful  menstruation,  with  scanty  flow  (Cactus, 
conium,  graph.,  puis.,  sepia),  and  urging  to  urinate,  worse  at 
night ;  menses  irregular.  Dr.  J.  Moore  ^  emphasizes  this  remedy 
in  his  list  of  remedies  for  dysmenorrhoea. 

Sepia  is  chiefly  useful  as  a  remedy  between  the  periods 
where  there  is  passive  congestion  of  the  pelvic  organs  (also 
sabina)  ;  severe  bearing-down  in  the  latter,  and  yellow  or  milky 
excoriating  leucorrhoea  worse  before  the  menses. 

Veratrum  vir.^  Dysmenorrhoea ;  menses  preceded  by 
intense  cerebral  congestion  in  plethoric  women.  It  has  been 
recommended  for  spasmodic  dysmenorrhoea  at  or  near  the 
climacteric,  six  drops  of  the  first  decimal  in  half  a  cup  full  of 
hot  water,  a  teaspoonful  every  fifteen  minutes  till  the  patient 
is  relieved. 

II  Viburnum  op.  cjb'^  is  best  given  in  hot  water,  at  intervals 
of  ten  or  fifteen  minutes.  It  is  one  of  the  best  remedies  to  allay 
the  pain,  but  often  requires  some  other  intercurrent  remedy  to 
effect  a  cure.  Cures  of  membranous  dysmenorrhoea  from  its 
use  have  been  reported. 5  Before  the  menses  there  is  bearing- 
down,  aching  in  sacral  and  pubic  region  ;  excruciating,  crampy, 
colicky  pains  in  hypogastrium ;  much  nervousness ;  and  occa- 
sional shooting  pains  in  the  ovaries.  The  pain  and  nervous  rest- 
lessness continue  during  the  flow  with  nausea.      Dr.   E.   M. 

'  If  there  is  dysmenorrhoea,  with  the  usual  flow,  Dr.  W.  H.  Holcombe  prefers 
caulophyllum. —  U.  S.  Med.  and  Snrg.  Jour.,  vol.  S,  p.  44. 

2  Monthly  Horn.  Review,  p.  671,  Nov.  i,  1871. 

3  The  following  case  of  long  standing  had  been  treated  by  able  physicians 
without  relief :  menses  regular  in  time,  quantity,  and  character,  but  preceded  for 
three  days  by  terrible  menstrual  colic  ;  pain  extends  all  over  the  body  ;  head  and 
face  look  bloodshot,  as  if  the  vessels  might  burst ;  pain  runs  into  the  head  from 
the  neck  ;  pulsation  in  head,  neck,  and  carotids  ;  sight  disappears  at  times,  every 
thing  moving  in  confusion  before  her  eyes  ;  tongue  feels  heav)^,  but  is  clean  and 
natural ;  great  thirst ;  pulse  full  and  bounding.  Verat.  vir.  ix.  was  given  in  five- 
drop  doses  every  half  hour,  for  six  hours,  at  the  time  of  pain.  In  four  months  she 
was  perfectly  well.  —  Dr.  Eggert:  Norlh-A7n.  Jour,  of  Horn.,  November,  1S73. 

*  Dr.  J.  C.  King,  Hahn.  Monthly,  p.  80,  1S77. 

s  Dr.  T.  C.  Hunter  :  Hahn,  Monthly,  January,  1S75. 


200  DYSMENORRHGLA. 

Hale  '  considers  it  almost  a  specific  for  neuralgic  and  spas- 
modic dysraenorrhoea. 

Xanthoxylon.  This  remedy  promises  to  become  almost 
a  specific  for  neuralgic  dysmenorrhoea,  with  very  severe  pain 
extending  down  the.  genito-crural  nerves,  down  the  anterior 
surface  of  the  thighs,  and  chiefly  left-sided,  though  in  recent 
provings^  the  right  ovary  was  particularly  affected.  Menses 
too  early ;  profuse ;  and  the  ovarian  pain  was  followed  by 
profuse  milky  leucorrhoea. 

Zincum  val.  is  a  favorite  remedy  with  some  physicians  for 
neuralgic  dysmenorrhoea  in  very  nervous,  hysterical  women. 
Dr.  E.  E.  Marcy  3  has  found  the  cyanuret  of  zinc  very  useful  in 
a  number  of  cases.  He  was  led  to  use  it  by  the  symptoms  of 
a  case  of  poisoning.* 

Other  Remedies  for  Consultation.  —  Agnus  cast.,5 
apis,*"  arg.  nit.,^  ars.,  cactus  grand.,  calc.  carb.,^  cannabis 
ind.    I  x.,9  coffea,  collinsonia,  conium,''    cupr.,'°   graph., 

'  American  Observer,  April,  1874. 

2  Publications  Mass.  Horn.  Med.  Soc,  vol.  viii.  p.  228,  1S85. 

3  North-Am.  Horn.  Journal,  vol.  ii.  p.  100,  1852. 

*  A  young  lady,  aged  twenty-two,  took  two  grains  of  the  cyanuret  of  zinc  twice 
a  day,  and  was  attacked  with  cramp-like  pains  in  the  uterine  region  ;  severe  pain 
in  the  back  ;  colic  pain  in  the  bowels;  vertigo;  convulsive  movements  in  various 
parts  of  the  body  ;  great  restlessness  and  nervousness  ;  oppressed  and  rapid  respi- 
ration ;  frequent  and  feeble  pulse. 

5  Recommended  by  Dr.  Winterburn,  in  Arndt's  System  Med.,  vol.  ii.  p.  402, 
for  obstructive  dysmenorrhoea. 

^  Miss ,  aet.  32.     Dysmenorrhoea  for  several  years ;    during   the  period 

severe,  spasmodic,  bearing-down,  labor-like  pains,  which  last  a  whole  day,  and  are 
followed  by  a  scanty  discharge  of  dark  bloody  slime  for  twenty  hours  ;  great  ema- 
ciation ;  wax-like  skin  ;  poor  appetite  ;  regular  but  hard  stool ;  croc,  puis.,  sabina, 
and  sulph.  were  of  little  service.  Apis  3,  a  day  before  the  period,  which  was  much 
less  painful,  and  the  blood  of  better  consistency.  Apis  repeated  before  the  next 
two  periods  completely  cured  her.  —  Dr.  J.  R.  Coxe-Hering,  Amer.  Azprfg., 
2S7. 

7  Dr.  John  Moore:  Monthly  Horn.  Review,  p.  671,  Nov.  i,  1871. 

5  Dr.  J.  T.  Kent  speaks  well  of  calc.  phos.  in  too  frequent  and  painful  men- 
struation, especially  at  puberty,  and  if  brought  on  by  exposure  to  wet.  —  Horn. 
World.,  p.  554,  Dec.  i,  1884. 

9  Dr.  Carfrae  speaks  highly  of  it.  —  HaJm.  Monthly,  p.  269,  vol.  vii.  1872. 

'°  Dr,  D.  Dyce  Brown,  Lecture  on  Dis.  Women.  — Monthly  Horn.  Review,  p. 
494,  Aug.  I,  1881. 


THERAPEUTICS  OF  DYSMENORRHOZA.      201 

hyosc,  'ignatia,"  ^  kali  carb.,^  lach.,  lil.  tig.,  mag.  mur., 
millefoliiim.s  naja,  natr.  mur.,  nitrate  of  amyl,'^  t  mix 
vom.^  phos.,9  Phytolacca,'"  plat./°  rhus  tox.,  sabina,  sar- 

'  Dr.  D.  Dyce  Brown,  Lecture  on  Dis.  Women.  —  Monthly  Horn.  Review,  p. 
464,  Aug.  I,  1881. 

2  ]y[i-s_ ^  aet.  26,  married  and  sterile;  excitable   temperament.     For  fifteen 

years  from  the  commencement  of  her  scanty  menstruation,  had  been  attacked  at 
every  period  by  violent  spasms  and  labor-like  pains  lasting  several  days.  Various 
remedies  did  no  good  ;  ignatia  cured  before  the  next  period,  and  she  has  been  well 
since.  Dr.  Hilberger,  who  reported  the  case,  believes  that  ignatia  is  the  best  remedy 
for  dysmenorrhcea  originating  in  irritability  of  the  nervous  system,  rather  than  con- 
gestion of  the  uterus.  —  Ruckert's  Klinische  Erfahrimgen,  Supplement,  p.  590. 

3  Dr.  H.  Goullon  mentions  this  remedy  for  dysmenorrhoea,  in  women  who 
menstruate  profusely  with  an  intermitting  pulse.  —  Allg.  Horn.  Zeitung,  p.  7, 
vol.  So,  1871. 

*  I  always  give  to  girls,  who  suffer  from  dysmenorrhoea,  a  dose  of  kali  carb. 
daily  for  a  week  before  the  approaching  menstruation,  especially  when  they  men- 
struate copiously,  and  there  are  intermissions  in  the  wave  of  the  pulse ;  sepia,  on 
the  contrary,  is  indicated  for  scanty  menses,  unilateral  headache  (migraine),  weak- 
ness of  sight,  nausea,  hard  stool  ;  Pulsatilla,  dysmenorrhoea  with  chilliness,  gastric 
complaints  (vomits  after  every  thing),  pressure  on  the  precordial  region,  soft  stool ; 
graphites  s.nd  ferrtim  have  simultaneously  constipation  and  anasmia. —  Dr.  H. 
Goullon,  Jun,,  in  Allg.  Hoin.  Zeit.  Translated  in  the  Journal  of  Horn.  Clinics, 
p.  130,  September,  1869. 

s  An  infusion  of  this  plant  and  a  single  application  of  iodized  phenol  appar- 
ently cured  a  case  of  membranous  dysmenorrhoea  (?).  —  Dr.  E.  M.  Hale,  Horn. 
Jour  of  Obst.,  January,  1S86,  p.  20. 

^  For  scanty  and  painful  menstruation,  congestive  dysmenorrhoea,  where  vib.  op. 
and  caul.  fail.  — Dr.  E.  M.  Hale,  Hahn.  Monthly,  p.  407,  1877. 

'  Fraulein ,  aet.  26.  Without  any  known  cause  menstruation  became  pain- 
ful at  seventeen  ;  has  been  treated  nine  years  unsuccessfully  by  the  opposite  school ; 
has  to  go  to  bed  ;  severe  cramping,  pressive  pain  from  the  uterus  towards  the  navel, 
sometimes  extending  to  the  stomach,  and  then  it  causes  great  nausea ;  chill  and  heat 
with  the  latter,  general  redness  of  the  face ;  nux  vom.  10  was  prescribed  ;  the  flow 
appeared  in  three  weeks,  and  lasted  five  days  ;  there  was  no  pain,  nor  did  it  recur 
afterwards.  —  Schwartz,  RUckert's  Klinische  Erfahrungen,  vol.  ii.  p.  238. 

^  Fraulein ,  aet.  20.     Dysmenorrhoea  for  lour  years,  following  the  abuse  of 

saffron.  Since  then,  the  flow  is  always  profuse  and  weakening  ;  eight  days  before 
the  period,  the  pain  begins  in  the  abdomen  ;  lancinating,  tearing,  and  bearing-down 
in  the  pelvis ;  it  is  most  severe  two  hours  after  the  flow  commences ;  the  cutting 
and  tearing  extend  from  the  pelvis  to  the  knees  ;  the  patient  cannot  straighten  the 
lower  limbs,  which  are  spasmodically  and  painfully  flexed  ;  the  hypogastrium  is  very 
s.nsitive  to  pressure.  Prescribed  nux  vom.  0,  six  drops  in  water,  four  spoonfuls 
of  it  each  day  for  eight  days  before  the  period.  There  was  improvement  at  the 
next  monthly,  and  in  a  few  months  the  patient  completely  recovered.  —  //'/(/. 

9  This  remedy  has  been  considered  one  of  the  most  important  for  membranous 
dysmenorrhoea,  and  is  advocated  by  Dr.  Eaton. 

'°  Dr.  John  Moore:  Monthly  Horn.  Review,  p.  671,  Nov.  i,  1S71. 


202  D  YSMENORRHCEA . 

saparilla/  secale  cor.  (expulsive  forcing  pains  with  dark, 
coagulated,  or  scanty  disharge),  silico-fluoride  of  cal- 
cium,^ 3  sulph.,4  strontium  carb.,^  thuja,  verat.  alb. 

Remedies  to  be  given  betiveen  the  Periods  for  Dysnien- 
orrh(ra.  — Cauloph.,'^  cimicif.,'*  cocc.,-*  collinsonia,"*  ham.,'* 


'  Menses  began  at  the  age  of  eleven  years,  and  with  the  exception  of  one  year 
she  has  had  dysmenorrhoea  for  twenty  years ;  the  monthly  begins  early  in  the 
morning,  with  bitter  vomiting,  diarrhoea,  fainting-fits,  very  cold  perspiration,  dread- 
ful pain  in  the  back,  thighs,  and  hypogastrium  ;  has  to  go  to  bed  ;  pain  lasts  two 
days,  and  goes  off  the  third  ;  tlic  left  nipple  is  i-etracted,  with  extreme  sensitiveness 
of  the  left  breast,  and  severe  pain  in  it  extending  down  the  left  arm.  She  was 
given  twenty-four  powders  of  sarsaparilla  30,  one  to  be  taken  at  night.  The  next 
menstruation  'was/ain/ess,  the  first  time  for  fifteen  years  ;  the  breast  was  still  very 
painful,  but  was  relieved  by  a  higher  dilution.  She  remained  well  at  time  of  report- 
ing the  case,  a  number  of  months  afterward.  —  Dr.  J.  C.  Burnett,  Horn.  World, 
p.  62,  Feb.  2,  1S80. 

'^  Silico-fluoride  of  calcium  (lapis  albus)  is  an  important  constitutional  remedy 
for  dysmenorrhoea  in  scrofulous  subjects.  Dr.  Whiting  of  Danvers,  Mass.,  writes 
me,  "I  think  it  is  best  indicated  in  subjects  of  a  lymphatic  temperament  with 
indurated  glands,  when  the  pain  precedes  the  flow ;  pathologically,  I  have  found 
chronic  congestion  of  the  cervix  uteri  to  such  a  degree  as  to  very  much  contract 
the  canal.  If  the  flow  is  not  attended  with  pain  till  the  day  of  termination,  at 
which  time  severe  forcing  pain  expels  large  clots,  strontium  carb.  is  the  remedy  ;  " 
also  if  "the  pain  comes  on  in  from  three  to  five  days  after  the  flow."  He  kindly 
sent  me  the  record  of  the  following  case  of  dysmenorrhoea,  for  which  he  gave 
sil.  fluor.  calc.  200,  dose  at  bedtime. 

Miss  ,  aet.  34 ;   she  had  measles  at  twenty,  since  then  has  had  pain  at 

commencement  of  menses  so  severe  for  first  day  or  two  as  to  cause  syncope ; 
Professor  Safford  found  the  cervical  canal  so  minute  she  could  not  pass  the  finest 
probe ;  patient  otherwise  healthy.  Four  months  later  she  wrote,  "  I  have  been 
waiting  to  thoroughly  test  the  medicine  before  writing  you.  The  first  month  after 
taking  it  I  had  none  of  that  terrible  nausea,  and  but  little  swelling  of  the  mamniEe, 
but  they  were  still  very  sore ;  pain  at  the  period  did  not  last  so  long,  but  was 
equally  intense ;  next  month  there  was  a  still  greater  improvement,  with  no  pain 
the  first  day  as  usual,  but  on  the  second  day  instead,  though  it  did  not  last  so 
long  ;  third  month,  no  premonitory  pain,  no  swelling  of  mammffi,  no  sensitiveness  ; 
have  not  lost  a  meal  this  month,  and  have  had  no  nausea.  For  first  day  and  a  half 
no  pain,  not  even  an  uncomfortable  feeling ;  but  after  working  hard  all  day,  had 
an  hour  and  a  half  slight  pain,  but  slept  all  night,  while  as  before  I  would  have 
been  tortured  for  two  or  three  days  and  nights.  I  can  live  and  be  happj',  should 
I  not  improve  more  ;  but  I  think  that  the  medicine  will  cure  me." 

3  Particularly  recommended  by  Dr.  Ludlam  for  membranous  dysmenorrhoea 
from  repelled  eruptions. 

''■  Dr.  D.  Dyce  Brown,  Lecture  on  Dis.  Women.  —  Monthly  Hoin.  Review, 
p.  464,  Aug.  I,  1881. 


REMEDIES  FOR  DYSMENORRHCEA.  203 

ignatia,  kali  nit./  mix  vom./  plat.,-  puis./  sabina,  scj^ia/ 
siLlpJmr,'^  xanthox.^ 

Ovarian  DysmenorrJicca.'^ — Apis  (right  ovary),  bell, 
(right  ovary),  calc.  c,  cactus  grand.,  coloc.  (left  ovary), 
ham.,  kali  iod.,  lach.  (left  ovary),  mere,  naja  (left  ovary), 
plat,,  thuja,  vespa  (left  ovary),  xanthoxylon  frax. 

Rheumatic  Dysmenorrhoea? — Aeon.,  bry.,  viacrotin, 
nux  vom.,  rhus  tox. 

Neuralgic  or  Spasmodic  Dysmenorrhea?  —  Aeon., 
agnus  cast.,  ammon,  carb.,  apis,  asclepias  tub.,  atropine, 
cactus,  cannabis  ind.,  castoreum,  cauloph.,  coffea,  collin- 
sonia,  cuprum,  gels.,  ham.,  hyosc,  ignatia,  HI.  tig.,  mag. 
carb.,  mosehus,  niacrotin,  nat.  mur.,  nux  vom.,  plat., 
puis.,  thuja,  veratr.  alb.,  veratr.  vir.,  vib.  op.,  xanthoxy- 
lon frax. 

Congestive  Dysmenorrh(£a. — Aeon.,  bell.,  bry.,  coccu- 
lus,  collinsonia,  gels.,  glonoine,  ham.,  kali  carb.,  lach., 
puis.,  sabina,  secale,  sepia,  veratr.  vir.,  xanthoxylon  frax. 

Membranous  Dysmenorrhcea.  —  Apis  (during  the  at- 
tack), borax,  bromine,  bryonia,  calc.  carb.,  cham.,  collin- 
sonia, cyclamen,  guiac,  iodine,  millefolium  (.''),  phos., 
sulph.,  viburnum  op. 

When  membranous  dysmenorrhoea  can  be  dated  from 
some  repelled  or  repercussed  skin  eruption,  the  follow- 
ing remedies  may  be  borne  in  mind  as  possibly  useful  ; 
sulphur  is  the  best  as  a  rule  :  — 

'^  If  from  an  eruption  like  tirticaria.^  —  Ars.  alb.,  rhus 
tox.,  urtica  urens. 

"  If  from  an  eruption  like  '  hives!  -^  K^x's,,  bell,  cham. 


'  Dr.  John  Moore,  Monthly  Horn.  Review,  p.  671,  Nov.  i,  1871. 

^  Dr.  D.  Dyce  Brown,  Lecture  on  Dis.  Women.  —  Monthly  Horn.  Review, 
p.  464,  Aug.  I,  1881. 

3  Compare  Ludlam,  Diseases  of  Women,  5th  ed. 

*  R.  Ludlam,   M.D.,  Transactions   World's    Horn.  Convention,   1S76,  vol. 
P-975- 


204  D  YSMENORRHCEA . 

^'- If  from  a  herpetic  or  vesicular  eruption.  —  Canth., 
rhus  tox. 

"  If  from  a  sgtiamous  or  scurfy  eruptio7i.  —  Borax, 
ars.,  mix  mos.,  dulc,  silicea,  sepia. 

^' If  a  scrofulous  or  unclassable  eruptiojt.  —  Sulph., 
calc.  carb.,  calc.  fluor.,  mere,  hepar  sulph. 

'' If  syphilitic. — Thuja,  nit.  ac,  mere,  iod.,  kali  iod., 
mezereum. 

''  If  from  suppressed  rubeola,  or  if  it  alternates  with 
ophthalmia.  —  Pulsatilla.  Or,  in  the  former  case  espe- 
cially. —  Cuprum  acet. 

"  If  it  is  erysipelatous. —  Bell.,  canth.,  rhus  tox.,  apis."  * 

'  Recommended  by  Dr.  Gray  in  drop  doses  of  the  tincture.  —  Tr ansae.  N.  Y. 
State  Soc.,  1873-74,  p.  384. 


DISPLACEMENTS  OF  THE  SEXUAL  ORGANS.     205 


CHAPTER    XV. 


DISPLACEMENTS    OF    THE    SEXUAL    ORGANS. 


npHESE  can  be  briefly  classified  as  follows  :  — 


Vagina 


Uterine 
displace- 
ments 


Prolapse  of  the  anterior  vaginal  wall ;  i.e.,  cystocele. 

Prolapse  of  the  posterior  vaginal  wall ;  i  e.,  rectocele. 

The  fundus  tipped  back  and  cervix  forward  without  flexion 

of  the  uterine  axis  ;  i.e.,  retroversiott. 
The  fundus  tipped  back  and  cervix  bent  down  with  flexion 

of  the  uterine  axis  ;  i.e.,  retroflexion. 
The  fundus  tipped  forward  and  cervix  backward  and  upward 

without  flexion  of  uterine  axis ;   i.e.,  anteversioit. 
The  fundus  tipped  forward  and  cervix  bent  downward  and 

forward  with  flexion  of  uterine  axis  ;  i.e.,  anteflexion. 
The  fundus  tipped  to  right  or  left  side  of  the  pelvis,  without 

flexion  ;   i.e.,  lateroversion. 
The  fundus  tipped  to  right  or  left  side  of  the  pelvis,  with 
flexion  of  the  cervix  and  body  ;   i.e.,  lateroflexion. 

(  First  degree.     Uterus  sags  down  so  that 

the  cervix  rests  on  the  pelvic  floor. 
J    Second  degree.    Uterus  descended  so  that 
the  cervix  presents  at  the  vulva. 
Third  degree,  or  procidentia.    Uterus  par- 
[       tially  or  entirely  outside  of  the  vulva. 
Complete  when  the  fundus  has  escaped 
through  the  cervix  so  that   the   endo- 
metrium forms  its  external  covering. 
Incomplete  when  the  fundus  has  not  es- 
caped from  the  cervix. 


Prolapsus  uteri, 

or 

"falling  of   the 

womb  " 


Inversion  of  the 
uterus 


The  ovaries  sometimes  become  displaced  either  in  or 
near  the  cul-de-sac  of  Douglas,  and  very  rarely  have 
been  known  to  enter  hernial  sacs. 


206    DISPLACEMENTS  OF  THE  SEXUAL  ORGANS. 

Displacements  are  very  rare  before  puberty,  infre- 
quent before  marriage,  more  so  after,  and  most  common 
after  child-bearing.  Prolapsus  of  the  vagina  is  almost 
invariably  caused  by  sub-involution  and  relaxation  of  the 
vaginal  walls,  associated  with  a  laceration  of  the  perineum. 
The  latter  also  favors  cystocele,  as  it  no  longer  supports 
the  base  of  the  bladder.  Distention  of  the  latter  from 
habitual  long  retention  of  urine,  and  chronic  constipa- 
tion, tend  to  produce  cystocele  and  rectocele,  especially 
in  the  conditions  just  mentioned.  When  the  uterus 
sags,  or  is  forced  low  down  in  the  pelvis,  the  length  of 
the  vaginal  tube  is  diminished  in  proportion,  and  it  con- 
sequently tends  to  roll  out. 

The  causes  of  uterine  displacement  are  much  more 
complex,  and  are  classified  in  the  following  table  :  — 


Lack  of  sufficient  [ 
support   to  the 
uterus 

Morbid  conditions 
of  the  uterus, 
especially  those 

'  increasing  i  t  s 
weight 


Force  acting  on 
the  uterus  from 
above 


Traction    on    the 
uterus 


Laceration  of  the  perineum. 

Relaxation  of  the  vagina  as  in  sub-involution. 

V\'eakness  of  the  uterine  ligaments. 

Tumors  of  the  uterus. 

Chronic  congestion. 

Hyperplasia  or  sub-involution. 

Lack  of  tone  or  relaxed  condition  of  uterine  tissue. 

Tight  or  heavy  clothing  supported  from  the  abdomen. 

Tumors,  or  a  distended  bladder,  crowding  the  uterus 
out  of  place. 

Sitting  in  easy-chairs,  the  pelvis  tilted  a  little  back- 
ward, and  the  body  bent  forward,  so  as  to  allow 
the  weight  of  the  abdominal  organs  and  forces 
exerted  on  them  to  act  diiectly  on  the  fundus 
uieri. 

Straining  at  stool. 

Falls  or  jumping. 

Undue  exercise,  such  as  lifting,  reaching,  and  too 
long  walks. 

Dragging  of  prolapsed  vagina. 

Abnormally  short  vagina,  especially  a  short  anterior 
wall. 

Cicatrices  or  contracting  masses  of  lymph  in  the 
pelvic  peritoneum  or  areolar  tissue. 


PROLAPSUS    VAGIN.-K.  207 

Displacement  of  the  ovaries  may  be  secondary  to  that 
of  the  uterus,  or  from  increased  weight  in  consequence  of 
congestion,  inflammation,  and  enlargement. 

The  symptoms  of  prolapsus  vagince  are,  a  sense  of 
dragging  in  the  pelvis,  and  a  feeling  of  something  pro- 
truding between  the  labia.  In  fact,  the  patient  usually 
states  that  she  thinks  she  has  "falling  of  the  womb." 
On  inspection,  the  anterior,  posterior,  or  both  vaginal 
walls  are  seen  to  roll  down  into  the  vulvar  commissure 
if  the  patient  is  told  to  force  down.  If  there  be  any 
doubt  as  to  the  nature  of  the  presenting  part,  the  finger 
in  the  rectum  will  enter  the  pouch,  and  establish  the 
diagnosis  of  rectocele,  or  the  silver  catheter  in  the  blad- 
der of  cystocele.  In  the  latter,  the  catheter  passes 
directly  downward  into  the  vesical  pouch,  which  often 
contains  a  variable  amount  of  urine.  The  patient  not 
being  able  to  empty  the  bladder  below  a  certain  level, 
the  residual  urine  becomes  ammoniacal,  and  cystitis  de- 
velops as  a  consequence  of  the  cystocele,  which  cannot 
be  permanently  cured  without  removing  the  cause. 

A  surgical  operation  '  only  will  cure  these  cases,  ex- 
cept in  very  rare  instances  of  acute  vaginal  prolapsus 
following  confinement.  There  is  scarcely  any  danger, 
and  a  properly  selected  operation  carefully  performed  is 
almost  sure  to  bring  relief.  If  the  patient  positiv^ely 
refuses  to  submit  to  an  operation,  a  large,  hard,  or  an 
inflated  rubber-ring  pessary,  tampons  of  antiseptic  wool 
or  oakum  medicated  with  some  astringent,  such  as  glyce- 
rine and  tannin,  alum,  or  fluid  extract  of  white-oak  bark, 
may  be  used,  and  supported,  if  necessary,  by  a  T-bandage. 
This  same  treatment  applies  to  prolapsus  of  the  second 
and  third  degrees. 

'  For  the  operation  for  cystocele,  see  Emmet,  Principles  and  Practice  of 
Gynsecology,  p.  35S,  1884;  and  Hegar  iind  Kaltenbach,  Operative  Gynakologie, 
p.  689.     For  laceration  of  the  perineum,  see  p.  90. 


2o8    DISPLACEMENTS  OF  THE  SEXUAL  ORGANS. 
RETROVERSION    AND    RETROFLEXION    OF    THE    UTERUS. 

These  have  similar  symptoms,  except  that  very  fre- 
quent and  sometimes  painful  micturition  is  much  more 
common  in  the  former  than  in  the  latter.  In  each,  there 
is  back-ache,  a  sense  of  weight  in  the  pelvis,  inability  to 
walk  but  a  short  distance  ;  going  up  and  down  stairs  is 
very  fatiguing  to  the  patient.  Inability  to  walk  any  dis- 
tance, with  bearing-down  in  the  pelvis,  is  a  very  char- 
acteristic symptom  of  uterine  displacement,  particularly 
if  it  has  existed  for  some  time.  Dysmenorrhoea  and 
tenesmus  of  the  rectum  are  sometimes  present.  Less 
often  the  local  symptoms  are  not  marked,  but  there  is 
spinal  irritation  and  exceedingly  severe  headache  just 
before  or  during  the  menses.  In  acute  cases  resulting 
from  a  fall,  the  pain  is  very  severe,  and  the  patient 
unable  to  walk. 

On  examination  the  fundus  is  felt  more  or  less  prom- 
inent in  the  cul-de-sac  of  Douglas,  and  the  space  ante- 
rior to  the  cervix  is  empty.  In  retroversion  the  cervix 
points  upward  against  the  base  of  the  bladder;  in  retro- 
flexion, the  cervix  is  nearly  or  quite  in  the  axis  ol  the 
vagina  ;  the  fundus  is  posterior  in  both  instances.  Too 
much  stress  cannot  be  laid  on  the  fact,  that  the  bi- 
viamcal  examination  and  the  accurate  outlining  of  the 
body  of  the  uterus  is  absolutely  essential  in  making  a 
diagnosis  of  uterine  displacement.  This  last  statement 
may  seem  quite  superfluous  ;  but  the  writer  has  repeat- 
edly seen  eminent  practitioners  place  one  hand  behind 
them,  the  forefinger  of  the  other  in  the  vagina,  and,  with 
their  eyes  rolled  up  to  the  ceiling,  make  a  diagnosis  (.-'). 
The  prominence  in  the  cul-de-sac  of  Douglas  may  give 
rise  to  the  suspicion  of  a  small  pedunculated  fibroid  on 
the  posterior  wall  of  the  uterus  ;  but  the  passage  of  the 
uterine  sound  will  at  once  decide  the  diagnosis,  for  if  it 


TREATMENT    OF  RETROVERSION,   ETC.      209 

is  a  fibroid  the  uterine  cavity  will  not  occupy  the  centre 
of  this  tumor.  An  enlarged  prolapsed  ovary  in  this 
situation  would  be  sensitive,  smaller  than  the  fundus 
uteri,  and  movable  if  not  fixed  by  adhesions. 

For  purposes  of  treatment,  these"  displacements  can 
be  divided  into  two  classes,  —  the  reducible  and  non- 
reducible. In  the  latter,  the  fundus  may  be  fixed  by 
adhesions,  or  some  local  contraction  of  tissue  in  the 
posterior  wall  of  the  uterus  may  spring  the  organ  back 
immediately  after  replacement.  Prolapse  of  the  ovaries 
with  fixation,  inflammation  of  the  cellular  tissue,  shallow 
posterior  pouch  of  the  vagina  from  insertion  of  the 
latter  near  the  tip  of  the  cervix,  and  the  presence  of  a 
fibroid  or  other  tumor  causing  the  displacement,  are  very 
troublesome  complications. 


G.  r/EMAiV/v.  cn. 


Fig.  65.     Nott's  Uterine  Elevator  and  Deprksser. 

Fortunately,  most  displacements  can  be  reduced  at 
once  with  prompt  relief  to  the  patient.  Place  her  in 
Sims'  position,!  with  her  clothing  loose  about  the  waist, 
and  the  hips  slightly  raised;  stand  behind  the  patient, 
and  pass  the  first  and  second  fingers  of  the  right  hand 
along  the  posterior  vaginal  wall  ;  make  gentle  pressure 
against  the  fundus  uteri  upward,  and  a  little  to  one 
side  of  the  sacral  promontory;  as  the  fundus  recedes, 
keep  the  middle  finger  in  place,  and  put  the  forefinger 
on  the  anterior  lip  of  the  cervix,  pressing  it  well  up  into 
the  hollow  of  the  sacrum.  If  necessary,  the  sound  can 
be  used  to  help  elevate  the  fundus.'  Sometimes  Nott's 
elevator  is  useful  to  elevate  the  fundus,  as  well  as  to 
press  the  anterior  wall  away  from  the  Sims'  speculum  so 
as  to  obtain  a  view  of  the  cervix. 

"^  See  chapter  on  Minor  Surgical  Gynjecology. 


2IO    DISPLACEMENTS  OF  THE  SEXUAL  ORGANS. 

The  same  manoeuvre  may  be  tried  with  the  patient 
in  the  knee-and-chest  position.  Some  authors  recom- 
mend introducing  one  or  two  fingers  in  the  rectum  to 
push  up  the  fundus,  but  this  is  scarcely  ever  necessary. 
When  the  fundus  is  so  large  and  heavy  that  it  does  not 
readily  slip  up,  it  is  a  good  plan  to  hook  a  tenaculum  or 
volsellum  forceps  into  the  cervix,  and  draw  it  down  a 
little,  so  as  to  gain  more  room  to  press  the  fundus  up. 

Unless  something  is  used  to  keep  the  uterus  in  place, 
it  will  become  displaced  again  in  a  few  minutes  after 
the  patient  takes  the  erect  position.  It  does  little  good, 
therefore,  to  reduce  this  dislocation  without  applying 
a  splint,  i.e.,  a  pessary,'  if  there  is  no  inflammation  ;  or, 
if  the  latter  be  present,  tampons  can  be  placed  behind 
the  uterus.  These  are  best  made  of  non-absorbent  cot- 
ton, antiseptic  wool,  oakum  or  sponge,  and  medicated 
with  glycerine,  iodine,  belladonna ;  or  some  preparation 
to  allay  pain,  such  as  chloral  hydrate,  conium,  or  hyo- 
scyamus.  These  tampons  should  be  removed  in  twelve 
hours,  or  earlier  if  pain  is  excited,  and  followed  by  copi- 
ous hot-water  injections.  A  well-adjusted  abdominal 
belt  to  take  off  the  weight  of  the  intestines  is  a  great 
help.^  The  uterus  must  be  replaced  and  tampons  in- 
serted from  three  to  four  times  a  week,  unless  it  increases 
the  inflammation  ;  then  the  case  must  be  treated  as  if  it 
were  pelvic  cellulitis,  and  no  manipulation  be  attempted 
till  the  inflammation  has  subsided.  If  a  pessary  is  fitted, 
tampons  are  unnecessary  except  to  allay  any  local  irri- 
tation. In  uncomplicated  cases,  if  the  pessary  is  well 
adjusted,  the  patient  need  not  be  seen  more  than  once 
in  one  or  two  months. 

The  above  treatment  also  applies  to  those  cases  where 
the  uterus  at  once  returns  to  displacement  after  being 

'  See  chapter  on  Minor  Surgical  Gynaecology. 


UTERINE   DISPLACEMENT   WITH  FIXATION.     211 

replaced,  either  from  changes  in  its  parenchyma,  or 
from  slight  and  lax  adhesions. 

Displacement  of  the  uterus  with  partial  or  complete 
fixation  is  tedious  to  treat,  and  requires  great  patience 
on  the  part  of  both  physician  and  patient.  No  force 
which  causes  much  pain  and  suffering  should  be  used 
to  replace  the  uterus.  It  is  very  apt  to  cause  inflam- 
mation of  the  peritoneum,  of  the  cellular  tissue,  or  the 
tearing  of  adhesions,  which  might  result  in  hematocele. 

The  best  method  of  treating  these  cases  is  that  of 
graduated  pressure  by  tampons  of  antiseptic  wool  or 
non-absorbent  cotton.  Place  the  patient  in  the  knee- 
chest  position,  or  a  modified  Sims',  having  her  lie  at 
least  one-third  over  on  her  abdomen,  and  the  hips  ele- 
vated not  less  than  three  inches  above  the  level  of  the 
shoulders.  Introduce  a  Bozeman's  or  Sims'  speculum, 
and,  in  addition  to  the  atmospheric  pressure,  push  up 
the  fundus  uteri  so  as  to  put  the  adhesions  on  the 
stretch  ;  now  take  dry  disks  of  the  wool  or  cotton,  and 
make  a  pyramid  or  column,  the  base  of  which  rests 
against  and  below  the  fundus,  and  the  apex  against  the 
rami  of  the  pubis  and  the  pelvic  floor.  The  object  of 
this  is  to  exert  elastic  pressure  on  the  adhesions,  which 
gradually  stretch  and  yield.  This  is  not  a  vaginal  plug, 
and  must  not  be  used  in  such  a  way  as  to  pack,  dis- 
tend, and  stretch  the  calibre  of  the  vagina. 

This  column  of  dry  wool  or  cotton  is  allowed  to 
remain  forty-eight  hours  ;  it  is  then  removed,  a  vaginal 
douche  of  hot  water  taken,  and  another  cotton  column 
put  in.  Of  course,  none  can  be  worn  during  the 
menstrual  period. 

This  course  of  treatment  may  have  to  be  pursued  for 
three  or  four  months  before  there  are  any  signs  of 
improvement ;  but  soon  after  that,  the  uterus  will  be 
found  a  little  more  movable.     This  gradually  increases 


2  12    DISPLACEMENTS  OF  THE  SEXUAL  ORGANS. 

till  the  fundus  can  be  thrown  forward,  and  a  pessary 
*  worn  with  ease.  It  has  been  the  writer's  experience, 
that,  after  some  mobility  is  once  secured,  progress  is 
much  more  rapid.  This  same  treatment  applies  to 
prolapse  and  fixation  of  the  ovary,  though  it  is  less 
satisfactory,  and  also  where  the  posterior  vaginal  pouch 
is  too  shallow.  Until  the  latter  can  be  stretched  suffi- 
ciently to  gain  greater  depth,  an  ordinary  vaginal  pessary 
cannot  be  worn,  and  it  is  necessary  to  give  external 
support  with  some  other  pessary,  such  as  Cutter's,  if 
the  cotton  is  not  used. 

If  the  cervix  is  flexed  on  the  body  of  the  uterus  so 
sharply  as  to  partially  close  the  canal,  and  cause  reten- 
tion of  fluids  above,  dysmenorrhoea,  or  sterility,  it  can 
be  dilated  by  Goodell's  method.' 

The  galvanic  current  is  also  advisable  in  the  treat- 
ment of  adhesions  ;  the  negative  pole  posterior  to  the 
uterus,  the  positive  on  the  hypogastrium.  A  mild 
current  should  be  used  every  second  day  for  three  or 
four  months  if  necessary ;  it  can  be  continued  to  ad- 
vantage with  the  use  of  tampons. 

One  of  the  best  cures  for  any  form  of  uterine  dis- 
placement is  pregnancy,  but  the  patient  must  take 
unusually  good  care  of  herself  after  delivery.  She 
ought  not  to  stand  on  her  feet  till  after  the  first  three 
weeks  of  the  puerperium  ;  and  any  work,  lifting,  or 
reaching,  for  the  succeeding  six  months,  should  be 
absolutely  prohibited.  The  uterus  must  be  examined 
occasionally  during  this  period,  any  tendency  to  dis- 
placement corrected,  and,  if  necessary,  either  a  pessary 
or  tampons  worn.  In  conection  with  the  treatment 
of  posterior  displacements,  see  also  the  treatment  of 
prolapsus  uteri. 

The  operation  of  shortening  the  round  ligaments  for 

'  See  chapter  on  Minor  Surgical  Gynaecology. 


ANTE  VERSION  AND   ANTE  FLEXION.  213 

inveterate  cases  of  posterior  displacement,  i.e.,  Alex- 
ander's operation,  has  not  been  tried  sufficiently  as  yet 
to  be  regarded  in  any  other  light  than  as  an  experiment.' 

ANTEVERSION  AND  ANTEFLEXION  OF  THE  UTERUS. 

The  symptoms  produced  by  these  conditions  are  very 
much  alike  ;  backache  and  rectal  irritation  are  far  more 
frequent  in  the  former  than  in  the  latter.  Both  are 
usually  accompanied  with  much  vesical  irritation,  diffi- 
culty of  walking,  dysmenorrhoea,  sterility,  leucorrhoea 
in  consequence  of  the  interference  with  circulation  and 
subsequent  congestion  of  the  uterus,  pain  in  and  about 
the  pelvis. 

Diagnosis.  —  On  bi-manual  examination,  the  fundus 
uteri  is  found  impinging  too  far  forward  on  the  bladder, 
and,  if  the  displacement  is  very  marked,  it  lies  down  on 
the  anterior  vaginal  wall  so  as  to  slightly  depress  it.  If 
it  is  a  case  of  anteversion,  the  cervix  is  pressed  up 
against  the  sacrum  in  proportion  as  the  fundus  tips 
down  in  front ;  if  anteflexion,  the  cervix  is  bent  for- 
ward in  the  vaginal  axis,  forming  an  angle  with  the 
body.  This  flexion  of  the  cervix  on  the  body  of  the 
uterus  may  be  so  acute  as  to  constrict  or  occlude 
the  cervical  canal,  and  to  cause  sterility  or  dysmenor- 
rhoea without  marked  displacement  of  the  fundus  uteri. 
It  is  important,  therefore,  to  ascertain  always  the  rela- 
tions of  the  cervix  with  the  body  of  the  uterus  in  every 
examination  for  the  diagnosis  of  a  displacement.  The 
introduction  of  the  uterine  probe  sharply  curved,  if 
necessary,  will  at  once  enable  the  examiner  to  decide 

'  Dr.  Polk  publishes  a  report  of  fifteen  cases  of  Alexander's  operation,  in 
thirteen  of  which  the  uterus  had  remained  in  place  as  far  as  he  had  been  able 
to  ascertain.  This  paper,  containing  a  description  of  the  operation,  as  well  as  its 
discussion  by  the  New-York  Academy  of  Medicine,  can  be  found  in  the  Medical 
Record,  July  3,  1886. 


214    DISPLACEMENTS  OF  THE  SEXUAL   ORGANS. 

whether  the  protrusion  is  a  fibroid  tumor,  cellulitic 
exudation,  or  the  fundus  uteri.  In  the  latter  only  is 
there  a  cavity  which  the  probe  readily  enters. 

The  uterus  is  replaced,  with  the  patient  in  the  dorsal 
position,  and  the  hips  well  raised  to  take  off  the  weight 
of  the  viscera  above  ;  the  operator  then  introduces  the 
first  two  fingers  of  the  left  hand  into  the  vagina,  presses 
up  the  fundus,  and  at  the  same  time  endeavors  to  push 
it  up  with  the  fingers  of  the  right  hand  placed  externally 
below  the  uterus.  Having  succeeded  in  raising  the 
fundus,  it  is  held  by  the  fore  or  middle  finger  in  the 
vagina,  and  the  hand  externally,  as  the  finger  of  the  for- 
mer pulls  the  cervix  from  behind  forward.  The  organ 
can  now  be  kept  in  position  by  vaginal  tampons  anterior 
to  the  cervix,  or  an  anteversion  cup  pessary.^  Geh- 
rung's '  or  Hewitt's  anteversion  pessaries  are  excellent 
in  some  cases,  but  the  former  is  liable  to  become  dis- 
placed. I'he  writer  has  succeeded  best  with  Thomas' 
open  cup,  or  his  modification  of  the  Hodge  pessary 
for  anteversion.  If  vaginal  support  cannot  be  given, 
one  of  Cutter's  anteversion  pessaries  is  often  useful, 
and  this  may  be  combined  advantageously  with  an 
abdominal  belt.'  In  case  there  is  a  flexion  of  the  cervix 
on  the  body  of  the  uterus,  causing  sterility  or  dysmen- 
orrhoea,  dilatation  of  the  cervical  canal,  by  Goodell's 
method,^  can  be  tried  ;  and,  if  this  fails,  incision  of  the 
posterior  lip  of  the  cervix  will  be  necessary  to  straighten 
the  canal.^  Intra-uterine  stem  pessaries  of  .vulcanite  or 
glass  have  been  worn  for  this  purpose,  sometimes  suc- 
cessfully ;  but  they  are  liable  to  excite  inflammation, 
and  require  very  careful  watching.  One  of  the  best 
instruments  of  this  class  is  Dr.  Thomas'  cup-and-stem 
pessary.'     Quite  recently.  Dr.  Graily  Hewitt  has  pro- 

'  See  chapter  on  Minor  Surgical  Gynfficology. 

2  See  Notes  on  Uterine  Surgery,  by  Dr.  Marion  Sims. 


PROLAPSUS   UTERL  215 

posed  to  straighten  the  canal  by  removing  a  longitudinal 
strip  of  mucous  membrane  from  the  posterior  surface  of 
the  cervix,  and  bringing  the  edges  together  with  sutures. 
The  cervix  is  thus  drawn  back,  the  canal  straightened, 
and  its  patency  increased  without  mutilation.  Success 
in  the  treatment  of  anterior  displacements  is  measured 
largely  by  the  perseverance  of  both  physician  and 
patient.  They  require  far  more  care  and  ingenuity 
than  retroversion  or  flexion. 

Lateral  Flexion  of  the  uterus  results  from  the  shorten- 
ing of  one  of  the  broad  ligaments,  and  is  diagnosed  by 
bi-manual  examination  of  the  uterus,  and  the  use  of  the 
probe.  It  is  very  difficult  to  treat,  and  requires  the  use 
of  the  cup-and-stem  pessary. 

PROLAPSUS    UTERI. 

Prolapsus  uteri  in  either  of  the  three  degrees  men- 
tioned is  readily  diagnosed.  The  symptoms  of  the  first 
degree  are  the  same  as  those  accompanying  retrover- 
sion, except  that  the  sense  of  weight  and  bearing-down 
is  much  more  marked.  In  the  second  degree,  rectal 
and  vesical  irritation  is  prominent  among  the  patient's 
complaints.  She  feels  the  protrusion  at  the  vulva, 
either  of  the  cervix,  or  the  cystocele  or  rectocele,  which 
commonly  come  down  in  advance  of  the  uterus.  In 
the  third  degree  the  symptoms  are  most  marked, 
and  the  patient  states  that  there  is  a  large  mass  outside 
the  vulva.  Walking  is  very  difficult,  and  cystitis  not 
uncommon.  Congestion  with  consequent  enlargement 
of  the  uterus  becomes  more  marked  in  the  successive 
degrees.  When  the  uterus  has  remained  for  some  time 
outside  of  the  vulva,  the  mucous  membrane  covering 
it  becomes  pale  and  thickened,  resembling  the  skin 
proper.  Ulcerations  from  friction,  and  cicatrices  where 
they  have  healed  up,  are  very  common  in  chronic  cases. 


2l6    DISPLACEMENTS  OF  THE  SEXUAL  ORGANS. 

The  Diagnosis  of  the  First  Degree  is  readily  made  by 
bi-manual  examination.  The  finger  at  once  impinges 
on  the  cervix,  and  the  entire  uterus  is  felt  to  be  much 
longer  in  the  pelvis.  In  the  second  degree  the  os  is  felt 
at  the  vulva,  and  prolapse  of  the  vaginal  walls  is  almost 
invariably  present.  A  peculiar  and  very  rare  form  of 
hypertrophy  and  elongation  of  the  cervix  might  be  mis- 
taken for  prolapsus,  though  the  two  are  more  often 
associated  with  each  other.  The  elongation  is  due  to 
peculiar  alterations  of  the  cervix  and  blood-vessels, 
rather  than  to  an  actual  increase  of  tissue  as  was  once 
supposed.  Inspection  is  sufficient  to  diagnose  the  third 
degree  of  prolapsus.  The  presence  of  the  cervical  canal, 
the  passage  of  the  sound  in  the  bladder  over  the  anterior 
surface  of  the  uterus,  and  the  empty  pelvis,  as  shown  by 
the  tip  of  the  finger  in  the  rectum  meeting  the  sound 
at  the  fundus  of  the  bladder  with  no  intervening  body, 
make  a  positive  diagnosis  from  any  other  condition. 

The  Prognosis,  as  regards  cure,  is  not  very  favorable 
in  the  worst  cases.  The  first  and  second  degrees  can 
often  be  cured  permanently. 

The  Treatment  varies  somewhat  with  the  form.  The 
first  degree  is  managed  in  the  same  way  as  retroversion. 
If  there  is  a  laceration  of  the  perineum,  an  operation' 
must  be  performed,  no  matter  what  the  form  of  pro- 
lapsus is,  as  no  vaginal  pessary  can  be  retained.  In  the 
second  degree,  in  addition  to  the  measures  taken  for 
the  preceding  form,  it  is  often  necessary  to  operate  on 
the  rectocele  or  cystocele ;  the  former  by  Emmet's,^  the 
latter  by  Emmet's ^  or  Simon's ■*  method.  In  complete 
prolapsus  after  the  child-bearing  period,  Neugebauer* 


1  Emmet,  Principles  and  Practice  of  Gynsecology,  1884,  p.  35S. 

2  Ibid.,  p.  374.  3  Ibid.,  p.  362. 

^  Hegar  und  Kaltenbach,  Operative  Gynakologie,  1881,  p.  689. 
s  Centralblatt  fur  Gynaliologie,  Nos.  i  and  2,  1881. 


TREATMENT  OF  PROCIDENTIA.  21/ 

has  united  the  anterior  and  posterior  vaginal  walls. 
This  is  known  as  Le  Fort's  operation.  Should  the  pa- 
tient not  be  fit  for  an  operation,  or  refuse  to  submit  to 
one,  astringent  tampons  of  alum,  tannin,  or  a  decoction 
of  white-oak  bark,  may  be  tried.  These  can  be  retained 
in  place  by  a  T-bandage  if  necessary,  and  must  be 
renewed  every  day.  They  are  seldom  curative,  but  will 
add  much  'to  a  patient's  comfort.  In  other  cases,  an 
abdomino-vaginal  supporter  is  beneficial,  such  as  Cut- 
ter's or  Macintosh's,  or  the  abdominal  supporter  '  pre- 
viously mentioned. 

When  the  uterus  has  protruded  from  the  vulva  for  a 
considerable  length  of  time,  it  becomes  very  much  en- 
larged, and  cannot  be  easily  replaced.  The  best  plan 
here  is  to  put  the  patient  in  bed,  apply  glycerine  dress- 
ings every  other  day  to  the  prolapsed  organ,  and  douche 
it  twice  daily  with  five  quarts  of  water  at  i  io°  F.  Cal- 
endula cerate  is  a  useful  application  to  the  erosions  or 
ulcerations.  Withm  a  week  the  uterus  will  be  so  much 
smaller,  that  it  can  be  readily  returned  within  the  pelvic 
cavity  in  the  following  manner.  Place  the  patient  on 
her  back,  with  the  thighs  flexed  on  the  abdomen,  and 
the  hips  slightly  elevated ;  raise  the  uterus  a  little,  and 
let  it  rest  in  the  hand  a  short  time  to  allow  the  venous 
blood  to  return  to  the  pelvis,  and  then  replace  it  in  the 
same  way  as  if  it  were  a  hernia  of  the  intestines,  i.e., 
return  first  that  part  which  came  down  last.  The  organ 
is  then  retained  by  some  of  the  methods  just  mentioned 
for  that  purpose.  In  many  cases,  however,  this  is  no 
easy  matter,  and  it  is  far  better  to  have  an  operation 
performed.  In  ladies  over  sixty  years  of  age,  it  is  best 
not  to  perform  the  usual  operation,  but  simply  close  the 
vaginal  outlet,  leaving  a  small  opening  for  the  escape  of 
any  discharge.      This  will    be   sufficient   to  retain  the 

'  See  chapter  on  Minor  Surgical  Gynaecology. 


2l8    DISPLACEMENTS  OF  THE  SEXUAL  ORGANS. 

uterus,  and  make  them  comfortable  during  the  few  years 
they  are  Hkely  to  live. 

In  inveterate  cases  of  posterior  displacement  or  pro- 
lapsus of  the  uterus,  which  operations  on  the  vagina 
fail  to  relieve,'  Dr.  Olshausen  recommends  opening  the 
abdomen,  and  stitching  the  fundus  of  the  uterus  to  the 
abdominal  wall  with  silver  wire.  One  case  was  a  fail- 
ure, but  others  were  cured  in  this  way. 

Inversion  of  the  Uterns  is,  what  the  name  signifies, 
a  turning  inside  out  of  that  organ,  so  that  its  cavity 
is  lined  with  peritoneum,  and  directed  toward  the  ab- 
dominal cavity,  with  which  it  is  continuous,  while  the 
external  covering  consists  of  the  endometrium.  It  may 
take  place  slowly  in  consequence  of  the  traction  of  a 
pedunculated  fibroid  or  polypus,  but  in  about  eighty- 
eight  per  cent  of  the  cases  it  follows  the  third  stage  of 
labor.  It  may  be  divided  into  the  acute  and  chronic 
forms  :  acute  when  the  inverted  uterus  has  not  under- 
gone involution  ;  chronic  after  this  stage  has  passed, 
and  when  it  is  caused  by  a  tumor. 

Acute  inversion  belongs  to  the  province  of  the  ob- 
stetrician, and  need  not  be  considered  here,  though  the 
manner  in  which  it  is  produced  may  be  of  interest.^  It 
is  believed  there  is  a  localized  weakness,  or  a  paralysis 
of  some  portion  of  the  uterine  wall,  probably  at  the 
placental  site,  or,  in  case  of  a  tumor,  a  fatty  degenera- 
tion or  loss  of  tone  about  the  site  of  attachment.  In 
either  case,  the  weak  portion  of  the  uterine  wall  sinks 
into  the  uterine  cavity  from  the  traction  on  the  placenta 
of  the  tumor,  or  from  abdominal  pressure  with  a  cor- 

'  Centralblatt  fiir  Gjnakologie,  No.  43,  p.  69S,  1SS6. 

2  Dr.  Henry  Crampton  has  an  interesting  article  on  Inversion  of  the  Uterus 
after  Parturition,  and  tabulates  the  records  of  one  hundred  and  twenty  acute  and 
one  hundred  and  four  cases  of  chronic  inversion,  in  the  American  Journal  of 
Obstetrics,  pp.  1009  and  1146,  18S5. 


INVERSION  OF   THE    UTERUS.  219 

responding  depression  on  its  peritoneal  surface.  The 
inverted  portion,  aided  by  muscular  contraction  of  the 
uterus  and  abdominal  pressure,  increases,  sometimes 
slowly,  or  so  rapidly  that  complete  inversion  may  take 
place  at  once,  or,  again,  it  may  be  arrested  so  that  only 
one  angle  or  horn  of  the  uterus  is  inverted  as  far  as  the 
internal  os  (incomplete  inversion)  or  through  the  external 
OS  (complete  inversion),  which  is  the  more  common  form. 
The  chief  symptom  of  inversion  is  very  profuse  menor- 
rhagia  and  metrorrhagia,  producing  great  anaemia  and 
weakness.  Besides  this,  there  are  the  bearing-down 
and  pelvic  pains,  so  characteristic  of  other  uterine  dis- 
placements. 

The  Diagnosis  is  not  difificult.  There  is  no  fundus 
felt  in  making  a  bi-manual  examination  in  the  usual 
manner.  The  sound  will  not  enter  the  cavity  by  the 
side  of  the  tumor  at  any  portion  of  its  circumference  to 
a  depth  of  two  and  a  half  inches.  If  the  tumor  is  drawn 
down  by  a  slip-noose  over  it  (volsellum  forceps  or  tenac- 
ula  will  tear  out  and  cause  bleeding),  the  finger  in  the 
rectum  can  feel  the  depression  on  the  peritoneal  surface 
of  the  tumor,  and  a  sound  passed  into  the  bladder  at  once 
impinges  on  the  rectal  finger,  showing  that  the  body 
of  the  uterus  cannot  lie  between  them.  Furthermore, 
the  external  surface  of  the  tumor  bleeds  easily,  and  is 
sensitive  to  the  prick  of  a  needle.  A  careful  examina- 
tion of  this  kind  will  distinguish  it  from  any  polypus  or 
pedunculated  fibroid,  the  only  conditions  for  which  it 
could  be  mistaken  by  the  most  superficial  examiner. 

The  Prognosis  is  unfavorable  for  most  cases,  in  conse- 
quence of  the  loss  of  blood,  unless  the  displacement  can 
be  reduced.  On  the  average,  two  out  of  three  can  be 
successfully  treated  in  this  way.  The  duration  of  the 
inversion,  even  if  it  be  for  many  years,  should  not  deter 
the  physician  from  careful  and  persistent  efforts  at 
reposition. 


220    DISPLACEMENTS  OF  THE  SEXUAL  ORGANS. 
The  Treatment  may  be  classified  as  follows  :  — 

r  Immediate,  by  the  hand  or  instrumental  aid. 
Reposition     -I  Moderate,  elastic  pressure  applied  continuously. 

1^  Thomas'  operation. 
Amputation. 

The  obstacle  to  reposition  is  the  contraction  of  the 
cervix  and  uterine  tissue,  especially  about  the  region  of 
the  internal  os,  forming  a  ring  around  the  prolapsed 
mass.  If  the  inversion  be  caused  by  a  tumor,  the  latter 
must  be  removed  if  not  malignant,  and  then  the  follow- 
ing measures  can  be  tried  :  Before  attempting  replace- 
ment of  a  chronic  inversion,  it  is  well  to  build  up  the 
patient's  strength,  and  hold  the  hemorrhage  in  check 
by  vaginal  irrigations  of  hot  water  (115°  F.). 

If  the  patient  does  not  object  to  taking  ether,  and  re- 
lays of  competent  assistants  can  be  had,  the  immediate 
method  of  reposition  by  the  hand  can  be  tried  first.  In 
preparation  for  this,  the  vagina  should  be  distended  by 
the  colpeurynter,  or  a  Barnes'  bag,  placed  well  up  in 
that  canal.  If  neither  of  these  is  at  hand,  packing  the 
vagina  full  daily  with  antiseptic  wool  might  be  tried. 
This  makes  room  for  the  operator's  hand,  and,  in  six 
cases,  has  been  known  to  cause  reposition.  This  will 
have  to  be  continued  for  ten  days,  or  longer,  till  the 
vagina  is  somewhat  expanded  ;  then,  having  the  patient 
anaesthetized,  and  in  the  lithotomy  position  on  a  table, 
seize  the  fundus  of  the  uterus  in  the  right  hand,  crowd- 
ing the  fingers  up,  as  far  as  possible,  along  the  base  of 
the  tumor.  The  fingers  are  then  expanded  to  press  the 
ring  out  as  the  fundus  is  crowded  up,  and  the  left  hand 
makes  counter  pressure  on  the  abdominal  wall.  A 
cone  of  wood  about  four  inches  long  is  sometimes  very 
useful  for  counter  pressure.  When  one  person  becomes 
tired,  another  takes  his  place,  till  the  ring  yields,  and 


INVERSION  OF    THE    UTERUS.  221 

the  fundus  is  finally  completely  replaced.  As  the  hand 
is  soon  tired,  Bryne's  repositor,  an  ingenious  cup-and- 
stem  instrument,  can  be  substituted  with  advantage. 

In  other  cases,  hooking  one  or  two  fingers  in  the 
peritoneal  depression  per  rectum,  and  exciting  counter 
pressure  with  the  thumbs,  has  been  tried  successfully. 
Dr.  Noeggerrath  advised  indentation  of  one  horn  of  the 
inverted  fundus,  and  to  crowd  this  upward  as  a  wedge 
in  the  canal,  reducing  the  displacement  in  this  way. 

If  these  efforts  are  unavailing  after  two  or  three  hours 
of  well-directed  taxis,  provided  the  patient's  condition 
admits  of  such  long  manipulation,  she  should  be  put 
to  bed,  and  a  colpeurynter,  or  vaginal  tampon,  used  to 
secure  what  has  been  gained.  If  the  fundus  has  risen 
through  the  external  os,  though  it  is  not  completely 
replaced.  Dr.  Emmet  advises  bringing  the  lips  of  the 
cervix  together  temporarily  with  silver  sutures,  so  as  to 
keep  what  has  been  accomplished,  and  in  hopes  it  may 
undergo  self-reposition. 

If  repeated  attempts  of  this  kind  fail,  elastic  pressure 
may  be  tried.  Some  operators  prefer  to  try  this  method 
first.  The  two  principles  involved  are  elastic  pressure 
on  the  inverted  fundus,  and  counter  pressure  on  the 
abdominal  wall.  The  first  is  met  by  applying  a  cup  to 
the  fundus,  with  a  firm,  slightly  curved  stem,  to  which 
are  attached  four  elastic  bands,  two  passing  in  front, 
and  two  behind,  to  be  fastened  to  a  firm  abdominal 
bandage.  Adhesive  plaster  is  useful  to  keep  the  band- 
age in  place.  Counter  pressure  can  be  exerted  by 
layers  of  cotton-batting,  over  the  hypogastrium,  secured 
by  a  broad,  firm  bandage  over  the  pelvis  similar  to  the 
obstetric  binder,  and  so  applied  as  to  exactly  meet 
the  pressure  from  below. 

While  an  old-fashioned  wooden  stethoscope  has  been 
successfully  used,  the  cup-and-stem  repositor  of  Thomas 


222     DISPLACEMENTS  OF  THE  SEXUAL  ORGANS. 

or  Bryne  is  preferable  to  exert  pressure  on  the  fundus. 
The  latter  must  not  only  be  in  the  direction  of  the  axis 
of  the  inverted  uterus,  but  also  in  the  axis  of  the  pelvis. 
This  can  be  regulated  to  a  nicety,  as  well  as  the  amount 
of  pressure,  by  tightening  one  or  more  of  the  elastic 
bands.  In  order  to  keep  the  uterus  from  bending  on 
itself,  it  is  padded,  on  all  sides,  with  antiseptic  wool ; 
the  cup  repositor  is  then  applied  to  the  fundus  in  the 
vagina,  packed  around,  in  the  same  way,  to  prevent 
slipping,  and,  finally,  the  elastic  bands  are  adjusted  so 
as  to  exert  only  a  moderate  pressure.  The  instrument 
must  be  removed  and  re-applied  each  day  to  observe 
the  effects,  and  note  any  tendency  to  sloughing.  This 
method  should  not  be  abandoned  till  it  has  been  tried 
at  least  three  weeks. 

Inversion  ^  of  the  uterus  has  been  successfully  treated, 
in  a  similar  way,  by  fastening  to  one  end  of  a  smooth 
piece  of  broomstick  a  soft,  thick  rubber  ring  (doughnut 
pessary),  which  would  fit  the  vagina  loosely,  and  when 
inserted  lie  against  the  fundus  uteri.  A  piece  of  soft 
rubber  tubing  was  tacked  on  the  other  end,  which 
projected  about  two  and  a  half  inches  from  the  vulva; 
the  two  forming  a  T-shaped  instrument,  the  wood  the 
upright  part  and  the  tubing  the  arms  of  the  T  This 
tubing  formed  an  elastic  strap  for  exerting  pressure 
against  the  fundus,  and  was  fastened  to  an  abdominal 
bandage  by  safety-pins.  Pressure  in  any  desired  direc- 
tion, and  to  any  reasonable  amount,  could  be  readily 
regulated  by  tightening  or  loosening  either  the  anterior 
or  posterior  end  of  the  tubing. 

The  instrument  was  adjusted,  and  the  patient  kept 
on  her  side.  Once  in  twenty-four  hours  it  was  removed, 
cleansed,  a  hot  vaginal  douche  given,  the  instrument 

'  Dr.  F.  W.  Johnson,  Am.  J.  of  Obstetrics,  p.  815,  1SS4. 


DISPLACEMENT  OF   THE  OVARIES.  223 

replaced,  and  the  patient  put  on  the  opposite  side.  As 
the  fundus  receded,  smaller  pessaries  were  used  till  it 
was  within  the  cervix.  A  small  round  stick  was  then 
substituted  for  the  piece  of  broomstick ;  and,  instead  of 
the  pessary,  a  rubber  cap,  such  as  is  used  on  chair-legs, 
was  slipped  over  the  end,  and  over  this  were  tied  two  or 
three  layers  of  a  rubber  bandage.  This  formed  the  pad, 
which  was  placed  against  the  fundus,  and  made  to  follow 
it  up  to  its  proper  place.  One  case  of  twenty-three 
months'  duration  was  thus  reduced  in  ten  days  ;  another, 
of  two  and  a  half  months,  in  two  days. 

The  majority  of  these  cases  can  be  reduced  by  the 
above  measures.  If  they  are  not  successful,  and  the  life 
of  the  patient  is  sufficiently  endangered  to  require 
amputation  of  the  inverted  uterus  if  it  is  not  replaced, 
Thomas' '  method  may  be  tried,  of  opening  the  abdom- 
inal cavity,  inserting  an  instrument  similar  to  a  glove- 
stretcher  into  the  peritoneal  opening  of  the  fundus, 
stretching  the  ring  of  constriction,  and  returning  the 
uterus  to  position  by  the  efforts  of  taxis  already  de- 
scribed. The  last  resource  of  all  is  amputation.^  The 
mortality  of  the  latter  operation  is  about  thirty-three 
per  cent. 

Displacement  of  the  Ovaries  is  of  common  occurrence. 
In  rare  instances,  the  ovary  has  been  known  to  enter 
hernial  sacs,  as  well  as  the  peritoneal  cavity  of  the 
inverted  uterus.  The  most  common  displacement  is 
prolapsus  into  the  pouch  of  Douglas,  or  at  one  side 
of  it,  and  when  fixed  by  adhesions,  and  complicated  by 
retroversion  or  flexion,  it  is  exceedingly  difficult  to 
treat  successfully. 

The  normal  position  of  the  ovaries,  like  the  uterus, 

'  Diseases  of  Women,  p.  440,  1878. 

-  Hart  and  Barbour's  Manual  of  Gynaecology,  p.  380,  1SS6;  also  Hegar  und 
Kaltenbach,  Operative  Gynjecology,  vol.  ii.  p.  133,  1S87. 


224    DISPLACEMENTS  OF  THE  SEXUAL  ORGANS. 

is  very  Variable  ; '  but  they  may  be  considered  prolapsed 
when  they  lie  below  the  level  of  the  junction  of  the 
cervix  with  the  body  of  the  uterus,  assuming  that  organ 
to  be  in  a  normal  position.^ 

The  frequency  with  which  prolapse  of  the  ovaries  is 
associated  with  posterior  displacements  of  the  uterus 
suggests  that  the  latter  drags  the  ovaries  after  it. 
This,  with  chronic  congestion  and  increased  weight  of 
these  organs,  accounts  for  the  etiology  of  nearly  all 
cases.     Jolts  and  falls  are  also  said  to  cause  it. 

The  Symptoms  are  those  of  pelvic  pain  radiating  in 
various  directions,  painful  coition  and  defecation,  with 
general  nervousness  and  irritability. 

The  Prognosis  for  recovery  is  fairly  good  for  recent 
cases  without  adhesions,  and  doubtful  with  the  condi- 
tions reversed. 

TJie  Treatment  consists  in  rest  during  menstruation, 
avoidance  of  sexual  excitement,  and  the  regulation  of 
the  bowels  so  as  to  secure  a  daily  movement.  Hot- 
water  vaginal  douches,  glycerine,  and  hamamelis,  either 
on  wool  tampons  or  mixed  with  the  last  pint  of  water 
used  as  a  vaginal  douche,  so  as  to  form  a  strong  solution, 
and  suppositories  of  belladonna,  iodoform,  or  similar 
substances,  are  useful  to  allay  the  congestion  and  sensi- 
tiveness. When  the  ovary  can  be  replaced  by  having  the 
patient  occupy  Sims'  position  with  the  hips  raised,  and 
gently  crowding  the  ovary  up  with  the  finger,  a  pessary 

As  the  result  of  about  twenty  post-mortem  examinat  ions  of  nulliparse  from 
fifteen  to  thirty  years  of  age,  and  a  number  from  one  to  fourteen  years  old, 
Waldeyer  believes  that,  in  the  normal  position,  the  ovaries  lie  just  below  the 
middle  of  the  linea  innominata,  with  their  Ion?  axis  perpendicular  when  the  body 
is  in  an  upright  position.  The  ureters  are  close  undr  the  hilum  of  the  ovary. 
He  states  the  uterus  is  in  a  position  of  anteversion  and  dnteRexion  when  the  blad- 
der is  empty,  and  confirms  the  views  of  Schultze  and  His.  —  Waldeyer:  Die 
Lage  der  iniiern  iveiblichen  Bechcnorgane  bet  NuUiparen,  Anaiomischer 
Anzeiger,  No.  2,  1886. 

^  For  palpation  of  the  ovaries,  see  chapter  on  Diseases  of  the  Ovaries. 


EN  DO  ME  TRITIS. 


233 


CHAPTER    XVI. 

ENDOMETRITIS. 

ENDOMETRITIS,  or  inflammation  of  the  lining  of 
the  uterine  cavity,  may  be  acute  or  chronic,  and 
affect  the  cervix,  body,  or  the  entire  endometrium  in 
either  form. 


Etiology. 


Symptoms  and  Diagtwsis. 


Acute 
endometritis 
(catarrlial). 


(Fibrinous.) 


(Hfemor- 
rhagic.) 


Differential 

diasnosis. 


Traumatism,  such  as 
improper  use  of  the  uter- 
ine sound,  tents,  intra- 
uterine pessary,  contact 
with  irritating  chemicals, 
abuse  of  coitus ;  effects 
of  cold,  especially  during 
menstruation,  witli  sup- 
pression of  the  flow;  in- 
flammation of  the  vagina 
extending  upward,  par- 
ticularly if  gonorrhoeal ; 
improper  evacuation  of 
retained  menses  from  im- 
perforate hymen  ;  acute 
eruptive  diseases,  such  as 
measles,  scarlatina,  small- 
pox, etc. ;  retrocession  of 
eruption  in  these  diseases. 


The  symptoms  are  not  severe  unless 
from  parturition,  or  evacuation  of 
retained  menstrual  flow.  There  is  a 
sense  of  weight,  dragging,  and  pain 
in  the  pelvis.  The  latter  may  also  be 
present  in  the  back  and  thighs,  and 
accompanied  by  frequent  and  painful 
micturition.  After  a  few  days  there 
is  a  leucorrhceal  discharge,  which  may 
be  sufficiently  irritating  to  excite 
vaginitis  and  produce  excoriations  on 
the  external  genitals. 

The  uterus  is  somewhat  enlarged, 
the  cervix  swollen  and  sensitive,  the  os 
open  and  the  margins  red;  the  canal 
is  filled  with  a  plug  of  albuminous  and 
very  tenacious  mucus. 


The  mobility  of  the  uterus,  the 
absence  of  inflammation  in  the  sur- 
rounding tissues,  and  the  lack  of 
marked  constitutional  symptoms,  will 
distinguish  it  from  other  diseases. 


234. 


EN  DO  ME  TRITIS. 


Portn. 


Etiology. 


Symptoms  and  Diagnosis. 


Chronic 

endometritis 

(cervical). 


Corporeal. 
(Fibrous.) 


(Hyperplas- 
tic, or 
polypoid. ) 


This  is  sometimes  the 
continuance  of  the  acute 
form  and  may  be  pro- 
duced by  the  same  causes. 
When  the  acute  form 
passes  into  the  chronic, 
there  is  often  present  a 
scrofulous  diathesis,  an 
enfeebled  condition  from 
any  of  the  causes  pro- 
ducing ansmia,  or  imper- 
fect circulation  from  mode 
of  dress,  disease,  etc.  The 
more  marked  exciting 
causes  of  this  disease  are 
laceration  of  the  cervix, 
polypi  in  the  cervix,  ob- 
struction to  escape  of 
menstrual  fluid,  sub-invo- 
lution, prevention  of  con- 
ception, or  the  induction 
of  abortion. 


Same  as  above,  and 
presence  of  tumors  in  the 
uterine  cavity  or  encroach- 
insr  on  it. 


The  only  symptom  which  may  bring 
the  patient  to  the  physician  is  leucor- 
rhoea.  There  is  a  sense  of  bearing- 
down  or  pelvic  pain,  worse  on  exercise, 
and  menstrual  disorders  not  infre- 
quently develop.  Symptoms  of  anae- 
mia are  often  present. 

Physical  examination  shows  the  cer- 
vix is  enlarged,  and  a  little  sensitive. 
There  is  usually  more  or  less  erosion 
about  the  os  ;  the  lips  of  the  cervix  may 
have  a  rough,  raw  appearance,  i.e., 
granular  degeneration,  and,  in  addi- 
tion, swollen  follicles  and  chalk-like 
concretions  are  seen,  giving  a  rasp- 
berry appearance  to  the  cervix.  When 
this  is  the  condition,  ectropium  is 
present,  and  there  is  almost  invariably 
laceration  of  the  cervix.  Sometimes 
the  cervix  has  a  normal  appearance, 
and  there  is  nothing  but  the  excessive 
amount  of  ten-acious  cervical  mucus 
to  mark  the  presence  of  the  disease, 
which  affects  the  glands  of  the  cervix 
in  particular.  In  the  chronic  form,  the 
cervix  suffers  most,  forming  cervical 
endometritis  or  endocervicitis. 

The  cervix  and  cavity  of  the  uterus 
may  be  simultaneously  or  separately 
affected.  In  corporeal  endometritis, 
the  leucorrhoea  is  less  tenacious  and 
viscid  than  when  it  comes  from  the 
cervix,  and  is  sometimes  tinged  with 
blood.  Menorrhagia  is  not  uncommon. 
The  endometrium  bleeds  easily,  and  is 
abnormally  sensitive  to  touch  with  the 
sound.  Sterility  is  often  present. 
These  symptoms  distinguish  corporeal 
from  cervical  endometritis,  as  the 
others  are  common  to  both. 


The    only   complications    are    those   resulting    from 
extension  of  the  inflammation  to  the  neighboring  struc- 


LEUCORRHCEA.  235 

tures.  Specific  endometritis  may  extend  to  the  peri- 
toneum through  the  Fallopian  tubes  with  serious  results. 
Endometritis  from  septic  puerperal  causes,  or  after  the 
evacuation  of  retained  menses,  may  be  of  a  dangerous 
or  even  fatal  character ;  otherwise,  the  prognosis  is 
favorable  in  acute  cases.  The  chronic  form  is  one  of 
the  most  common  of  the  gynaecological  diseases,  and, 
at  the  same  time,  one  of  the  most  difficult  to  cure, 
especially  when  associated  with  ovaritis.'  As  a  general 
rule,  the  more  the  Nabothian  glands  are  involved,  the 
more  obstinate  is  the  disease. 

The  pathology  of  endometritis  is  very  like  inflamma- 
tion of  mucous  membrane  elsewhere,  plus  the  inflam- 
mation of  the  utricular  and  Nabothian  glands,  and  the 
increased  secretion  in  consequence.  The  causes  of  this 
disease  are  very  similar  to  those  producing  catarrhal 
inflammation  in  other  portions  of  the  body,  and  the 
same  general  principles  of  treatment  apply  to  both  ;  but 
how  far  those  remedies  particularly  adapted  to  the  one 
will  cure  the  other,  is  not  known. 

LEUCORRHCEA. 

It  may  not  be  out  of  place  here  to  call  special  atten- 
tion to  this  symptom  of  catarrhal  inflammation  of  the 
lining  membrane  of  the  genital  tract.  When  it  occurs 
as  a  symptom  of  vulvitis  or  vaginitis,  the  reader  is 
referred  to  those  chapters. 

From  a  practical  point  of  view,  leucorrhoea  may  be 
divided  into  two  classes  :  physiological  and  pathologi- 
cal. The  former  is  of  slight  amount,  short  duration, 
and  is  more  often  found  in  women  having  a  scrofulous 


"  An  excellent  study  of  the  relation  of  endometritis  to  ovarian  disease,  b}^  Dr. 
Mary  Putnam  Jacobi,  will  be  found  in  the  American  Journal  of  Obstetrics,  p.  352, 
April,  1886.  Compare  also  her  Studies  in  Endometritis,  American  lournal  of 
Obstetrics,  1885. 


236 


ENDOME  TRITIS. 


taint ;  for  example,  some  women  have  a  slight  leucor- 
rhoea  during  cold  weather,  the  mild  forms  of  leucorrhoea 
in  pregnancy,  a  small  amount  of  leucorrhoea  immedi- 
ately before  and  just  after  the  menses,  which  entirely 
ceases  during  the  interval.  In  the  last  instance  it  may 
be  that  the  leucorrhoea  is  a  safety-valve  of  the  organism, 
the  sudden  suppression  of  which  by  astringent  injec- 
tions would  result  in  inflammation  of  the  pelvic  struc- 
tures, which  would  not  be  the  case  were  it  checked 
more  gradually  by  milder  treatment.  The  leucorrhoea 
during  cold  weather  is  often  cured  by  wearing  closed 
flannel  drawers,  and  using  a  chair  in  a  warm  room 
instead  of  the  cold,  open  privy.  The  great  character- 
istic between  physiological  and  pathological  leucorrhoea 
is,  that  the  former  is  transient,  the  latter  constant  but 
subject  to  variations  ;  the  former  requires  very  little 
treatment,  the  latter  may  tax  the  powers  of  the  most 
astute  physician. 

Though  the  etiology  is  that  of  the  disease  producing 
the  discharge,  such  as  endometritis,  there  are  three 
great  causes  of  leucorrhoea,  which  must  be  remem- 
bered for  the  successful  treatment  of  this  affection. 


Congestion 
of  the  pel-  \ 
vie  organs 

I 


I.  Scrofulous  dyscra-  \ 

sia       associated   !  ^' 

with  anemia  or   i    ^°°  frequent  parturition  or  prolonged  lactation. 

chlorosis  J   Anything  producing  anaemia. 

f  Retarded  portal   f  Diseases  of  the  heart  or  liver. 

Chronic  constipation. 

Growths  in  the  uterus. 

Displacement  of  the  uterus. 

Sub-involution. 

Ovaritis. 

Incomplete  or  excessive  coition. 

Masturbation. 

Acute  exanthemata. 

Ascarides,  especially  in  little  girls. 


circulation 


Local  irritation    \ 


3.  Specific 


Gonorrhoea. 
Syphilis. 


LEUCORRHCEA.  237 

Three  forms  of  leucorrhoea  are  usually  described  : 
vulvar,  vaginal,  and  uterine.  The  first  is  sebaceous  or 
sero-purulent ;  seldom  profuse.  The  second  has  an  al- 
kaline re-action,  usually  of  milky  character,  and  contains 
an  abundance  of  pavement  epithelium  undergoing  fatty 
degeneration.  The  third  has  often,  but  not  always,  an 
alkaline  re-action  ;  the  discharge  from  the  cervix  is  thick 
and  gelatinous,  from  the  uterus  thinner  and  more  like 
mucus.      The  last  two  forms  are  often  found  together. 

Leucorrhoea  from  specific  causes  usually  flows  from 
both  urethra  and  vagina,  has  an  acid  re-action,  and  is 
characterized  by  its  thick,  yellow,  or  purulent  appear- 
ance. 

A  very  offensive  watery  discharge,  sometimes  con- 
taining blood,  is  one  of  the  earliest  symptoms  of  malig- 
nant disease,  and  calls  for  a  careful  examination. 

Whatever  the  form  of  leucorrhoea,  the  principles  of 
treatment  are  the  same.  The  axe  must  be  applied  to  the 
root  of  the  tree ;  the  cause  must  be  carefully  investi- 
gated and  removed.  The  treatment  must  be  aimed  at 
the  source  of  the  disease.  If  anaemic,  the  patient  must 
be  built  up  by  generous  diet,  out-door  air  and  exercise, 
sea-bathing  or  a  sponge-bath  with  salt  water  and  vigor- 
ous friction,  as  well  as  the  use  of  proper  medicine  ;  if 
the  uterus  is  displaced,  it  must  be  replaced ;  if  the 
ovaries  are  inflamed,  they  must  receive  particular  atten- 
tion. It  is  hardly  necessary  to  recapitulate  each  par- 
ticular cause,  the  treatment  of  which  will  be  found  in 
its  appropriate  chapter. 

The  importance  of  a  generous  diet  cannot  be  over- 
estimated. The  loss  of  albumen  from  the  system  is  a 
constant  drain,  and  tends  to  increase  the  ansemia. 
Nature  tries  to  offset  it  by  arresting  the  menstrual 
flow  ;  but  the  waste  in  the  system  needs  replenishing, 
not  by  the  pickled-limes,  olives,  chalk,  and  slate-pencils 


238  ENDOMETRITIS. 

of  school-girls,  nor  the  highly-seasorled  food  of  their 
mothers,  but  by  plenty  of  lean  beef,  mutton,  milk,  and 
eggs,  —  in  short,  a  plain  non-stimulating  diet.  Where 
the  digestion  is  weak,  and  meat  cannot  be  borne,  the 
author  has  successfully  used  beef-juice,  prepared  in 
the  following  manner:  Take  a  juicy  steak,  preferably 
the  round  ;  cut  off  the  fat  ;  broil  it  quickly  over  hot 
coals,  merely  enough  to  sear  the  surfaces  without  cook- 
ing the  meat  inside.  Cut  a  few  gashes  in  it,  and  press 
out  the  juice  with  a  lemon-squeezer  or,  far  better,  a 
meat-press.  This  can  be  seasoned,  and  taken  clear  or 
mi.xed  with  bread-crumbs.  In  this  way  a  patient  can 
easily  take  the  juice  of  two  or  three  pounds  of  steak  a 
day,  and  derive  much  more  benefit  from  it  than  that 
popular  delusion,  beef-tea,  which  is  stimulating,  but 
contains  scarcely  any  nourishment.  The  local  and 
medical  treatment  is  the  same  as  for  endometritis,  of 
which  it  is  a  symptom. 

Tlie  Treatment  of  Acute  Endometritis  consists  in 
removing  the  exciting  cause  so  far  as  possible,  enjoin- 
ing perfect  sexual  and  physical  rest,  and  the  use  of 
copious  hot-water  vaginal  douches  night  and  morning. 
No  local  treatment  is  necessary. 

TJie  Treatment  of  Chronic  Endometritis  is  a  different 
matter,  and  may  baffle  the  physician's  skill  to  cure  it 
permanently,  particularly  if  the  body  of  the  uterus  is 
affected.  Vaginal  douches  should  be  employed  twice 
daily,  to  which  a  little  impure  carbolic  acid,  calendula, 
eucalyptus,  hydrastis,  or  glycerine  can  be  added.  If 
the  cervical  canal  is  very  small,  or  the  external  os  is 
a  little  contracted  so  that  the  cervical  secretions  are 
somewhat  pent  up,  it  is  absolutely  necessary  to  dilate 
the  canal  or  incise  the  cervix  sufficiently  to  allow  them 
a  free  exit. 

Before  a  local  application  can  be  made  with  any  de- 


TREATMENT  OF  ENDOMETRITIS,    ETC.      239 

gree  of  efficiency,  the  plug  of  mucus  in  the  cervical  canal 
must  be  removed,  which  is  not  always  an  easy  matter, 
as  the  mucus  is  so  tenacious.  It  can  be  done  with  a 
uterine  piston  syringe  having  a  short  piece  of  rubber 
tubing  on  the  nozzle,  which  is  introduced  well  into  the 
external  os.  The  plug  of  mucus  is  sucked  in  by  draw- 
ing the  piston  quickly  out  ;  or  a  small,  narrow  piece  of 
dry  sponge  can  be  introduced  in  the  canal,  and  rotated 
with  the  dressing  forceps  so  as  to  entangle  and  bring 
out  the  thick  mucus  :  but  it  is  of  no  use  to  try  it  with 
cotton.'  Sometimes  a  stream  of  water  from  a  syringe 
will  cleanse  the  canal  most  effectually. 

After  the  diseased  mucous  membrane  has  been 
thoroughly  cleansed  by  one  of  these  methods,  an  appli- 
cation can  be  made  of  impure  carbolic  acid,  eucalyptus, 
Churchill's  tincture  of  iodine,  iodized  phenol,  or  thick 
extract  of  pinus  canadensis.  Gelatine  or  cocoa-butter 
pencils  of  iodoform,  tannin,  hydrastis,  etc.,  are  favorites 
with  some  ;  or  the  same  substances,  including  calendula, 
eucalyptus,  and  boracic  acid,  may  be  used  as  a  cerate  or 
mixed  with  glycerine.  An  occasional  application  of  a 
solution  of  nitrate  of  silver  (five  grains  to  the  ounce) 
is  sometimes  necessary  on  account  of  its  stimulating 
properties  ;  but  its  use  should  be  restricted,  as  severe 
and  almost  incurable  ovaritis  has  resulted  from  its  use.^ 

The  distended  follicles  must  be  opened,  and  if  they 
are  seriously  involved  it  is  often  necessary  to  remove 
them  with  a  curette.^     Sponge  tents  are  also  used  for 

'  The  local  use  of  the  peroxide  of  hydrogen  (twelve  volumes)  has  been  recom- 
mended for  this  purpose,  but  the  author  cannot  speak  very  favorably  of  it  from  a 
limited  trial,  except  when  the  discharge  is  purulent.  The  pieparation  is  very 
unstable,  and  soon  deteriorates. 

^  For  the  indications  for  the  use  of  these  applications,  see  p.  37. 

3  The  writer  has  noticed  that  a  very  large  proportion  of  cases  of  leucorrhoea 
were  associated  with  laceration  of  the  cervix,  and  promptly  cured  by  operating  on 
the  latter.  When  the  lacerated  surfaces  and  cervical  canal  are  both  filled  with 
distended  follicles  and  nodules,  Scliroeder's  method  of  excision  of  the  cervical 


240 


ENDOMETRITIS. 


this  purpose,  and  exercise  a  decided  alterati\'e  effect  on 

the  tissues. 

The  use  of  injections  into  the  uterine  cavity  should 

never  be  attempted  unless  the  canal  is  patulous.  It  is 
a  question  with  the  writer,  how  far  local 
applications  to  the  endometrium  of  the 
body  of  the  uterus  will  result  in  permanent 
benefit  to  the  patient.  This  membrane  is 
constantly  undergoing  degeneration  and 
repair  from  the  muscular  structures  be- 
neath. These  must  be  put  in  a  condition 
to  produce  a  healthy  lining  to  the  cavity, 
K     and    this    can    be    best    accomplished    by 

%    constitutional    treatment.       Excellent   au- 

j 

^  thorities,  however,  recommend  the  use 
g  of  the  compound  tincture  of  iodine  or 
I  iodized  phenol ;  and  others  believe  in 
thorough  irrigation  of  the  cavity  with  a 
'^  double-current  uterine  catheter,  or  the  ap- 
^  plication  of  iodoform  in  pencils  or  powder. 
Dr.  Gehrung '  has  invented  an  ingenious 
instrument  for  blowing  powder  into  the 
uterine  cavity  or  vagina.  Should  severe 
menorrhagia  be  a  prominent  symptom,  it 
probably  depends  on  the  presence  of  polypi 
or  a  fungoid  degeneration  of  the  endome- 
trium. In  these  cases  the  thorough  use 
of  the  dull  wire  curette,  followed  by  the 
local  application  of  iodine,  will  control  the  menorrhagia. 
It  is  exceedingly  difficult  to  cure  chronic  endometritis 
without  perfect  rest  during  the  menstrual  period,  and 
absolute  sexual  abstinence. 


membrane  can  be  combined  with  Emmet's  operation.     For  a  description  of  this 
operation  see  Schroeder,  Krankheiten  der  weib.  Geschiechtsorgane,  18S1,  p.  135. 
'  American  Journal  of  Obstetrics,  p.  1233,  December,  1886. 


THERAPEUTICS  OF  ENDOMETRITIS,   ETC.     24 1 

In  leucorrhcea  depending  on  a  gonorrhoea!  vaginitis 
or  endometritis,  Fritsch  '  warmly  recommends  a  solu- 
tion of  equal  parts  of  chloride  of  zinc  and  water.  20  g. 
(one  tablespoonful)  of  this  solution  is  added  to  a  litre 
of  water  (one  quart+),  and  used  for  a  vaginal  injection 
at  a  temperature  of  30°  R.  (99.5°  F.),  and  continued 
through  menstruation  if  necessary.  The  leucorrhoea 
generally  ceases  after  ten  injections,  but  returns  if  the 
cervix,  endometrium,  and  tubes  are  involved.  In  this 
case  the  uterine  cavity  is  cauterized  with  a  stronger 
solution  of  chloride  of  zinc,  and  an  iodoform  pencil 
introduced. 

THERAPEUTICS. 

In  prescribing  for  leucorrhoea,  the  character  of  the 
discharge  is  generally  less  important  than  the  general 
symptoms,  and  those  arising  from  the  physical  condition 
of  the  patient.  The  symptoms  attending  the  menstrual 
flow,  and  of  the  ovaries,  are  of  no  little  value  in  select- 
ing the  remedy. 

II  Antimonium  tart.  Many  physicians  consider  this  one 
of  the  most  important  remedies  for  chronic  corporeal  cervicitis,^ 
the  cervix  is  much  enlarged,  with  a  superficial  erosion  about  the 
OS.  It  is  an  excellent  remedy  both  for  the  inflammation  of 
the  endometrium,  and  for  the  body  of  the  cervix. 

j  Arsenicum.  Chronic  endometritis  of  the  body  of  the 
uterus,  particularly  if  menorrhagia  is  a  marked  symptom. ^  It  is 
also  useful  for  endocervicitis,  if  the  patient  is  weak,  the  dis- 
charge thin,  and  the  pelvic  pains  of  a  burning  character ;  leu- 
corrhcea profuse,  yellow,  thick  (Hydrastis,  kali  bi.),  corroding 
(Kali  carb.)  ;  pressive,  burning,  lancinating  pains  in  the  ovary, 

'  Dr.  H.  Fritsch  :  Die  Behandlung  der  gonorrhoischen  Vaginitis  tind 
Endometritis.     Centralblatt  fiir   Gyncikologie,   No.   30,   p.477.      18S7. 

2  Dr.  Ludlam,  New-England  Medical  Gazette,  November,  1S77 ;  and  Dr. 
Gourbeyre,  Clinique,  July,  1S81. 

3  Halin.  Mat.  Med.,  Part  I.  p.  18  (arsenic). 


242  ENDOMETRITIS. 

more  often  the  right,  extending  into  the  thigh,  which  feels 
numb  and  lame,  worse  from  motion  or  bending  over.  White 
leucorrhoea,  acute  from  taking  cold,  or  debility  of  exhausting 
disease,  cancer,  kidney,  cardiac,  or  pulmonary  disease. 

II  Belladonna  is  an  invaluable  remedy  in  acute  endo- 
metritis either  of  the  body  or  cervix  of  the  uterus ;  also,  if  the 
inflammation  has  extended  beyond  the  endometrium,  so  as  to 
involve  the  muscular  tissue.  The  cervix  is  very  sensitive,  swollen, 
and  reddened  ;  the  mucous  membrane  about  the  os  is  of  a  bright 
scarlet  hue,  and  there  may  be  superficial  excoriations  ;  there  is 
much  heat,  dryness,  throbbing  pain,  and  bearing-down,  in  the 
pelvic  organs. 

Bryonia.  If  the  endometritis  follows  imperfect  develop- 
ment or  retrocession  of  some  skin  eruption,  and  there  are  also 
other  symptoms  belonging  to  this  remedy,  it  deserves  a  trial, 
though  the  author  has  not  met  with  reports  of  cases  verifying 
this  indication. 

II  Calc.  carb.  Compare  also  calc.  phos.  It  is  especially 
useful  for  scrofulous  patients,  and  is  indicated  more  by  the  gen- 
eral than  the  local  symptoms,  when  strumous  disease,  especially 
of  the  cervical  glands,  is  present ;  perspires  on  the  least  exertion, 
particularly  about  the  head  ;  very  hungry  in  the  morning,  acidity 
of  the  stomach  ;  feet  feel  cold  and  damp  ;  menses  too  early  and 
too  profuse  ;  leucorrhcea  before  the  menses ;  milky  leucorrhoea 
(Coni.,  lye,  puis.,  sepia,  sulph.  ac),  at  times  profuse,  with 
itching  and  burning.  Dr.  Ludlam  thinks  this  remedy  is  not 
indicated  in  cervical  endometritis,  unless  the  inflammation 
extends  up  beyond  the  internal  os  uteri.  Leucorrhoea  in 
children  (Sepia,  cannab.  sat.). 

Cimicifuga.  This  remedy  is  warmly  praised  by  Dr.  D. 
Dyce  Brown,'  in  a  very  able  article  on  the  Treatment  of 
Endocervicitis.  The  general  symptoms  are  of  great  importance. 
The  patient  is  nervous,  tieui-algic,  and  hypercesthetic,  but  not  so 
hysterical  as  the  ignatia  patient ;  the  uterus  is  engorged ;  the 
cervix  eroded  and  hypertrophied  ;  examination  shows  a  marked 
sensitiveness  of  the  pelvic  organs,  especially  the  ovaries,  and 

'  Transactions  Internat.  Horn.  Congress,  London,  p.  244,  1881. 


THERAPEUTICS  OF  ENDOMETRITIS,   ETC.    243 

the  left  rather  more  than  the  right,  not  from  pain  but  from  the 
general  hypersesthesia ;  headache  in  the  vertex,  forehead,  over 
the  eyes,  or  in  the  eyes ;  the  pain  is  dull,  pressive,  and  heavy 
in  the  eyes,  and  there  is  the  same  heavy  pressure,  with  a 
drawing  sensation,  in  the  fundus  of  the  eyeball ;  the  pupils 
dilated. 

Graphites.  Profuse  leiicorrhxa  of  very  thm  white  mucus, 
with  weakness  in  the  back ;  leucorrhoea  occurs  in  gushes  day 
or  night ;  abdomen  distended ;  menses  delayed,  scanty  and  pale. 
Dr.  Jahr  concurred  with  Dr.  Wahle  in  recommending  it  for  the 
cauliflower,  wart-shaped  excrescences  on  the  neck  of  the  uterus. 
The  latter  also  prescribed  it  for  induration  and  congestion  of 
the  cervix ;  painful  tubercles  on  the  sides  of  the  cervix ;  great 
weight  and  lancinating  pains  in  the  lower  part  of  the  abdomen 
and  uterus.  These  point  to  graphites  as  a  valuable  remedy  for 
laceration  of  the  cervix  with  follicular  disease. 

Guaco.  Dr.  Eduardo  Fornias,'  in  his  fecture  on  "exotic 
drugs"  states,  ihaX guaco  taken  in  appreciable  doses  produces 
a  copious,  corrosive,  putrid  leucorrhoea,  which  is  very  debilitat- 
ing. A  lady  who  had  never  suffered  from  these  symptoms  be- 
fore taking  the  drug,  reports  that  she  sometimes  "  felt  as  if  fire 
were  running  out  of  her  parts,  and  that  the  inside  of  her  thighs 
was  materially  tanned,  and  her  clothing  always  stained  yellow ; 
she  complained  also  of  a  terrible  itching  and  smarting,  especially 
at  night." 

Helonias.  Leucorrhaa  with  general  debility  ;  melancholia 
with  a  sensation  of  weight,  soreness,  and  dragging  in  the  uterus. 
It  may  be  accompanied  by  intense  pruritus,  heat,  and  swelling, 
with  exfoliation  of  the  epidermis. 

Hepar.  Scrofulous  subjects;  profuse  catarrhal  discharge, 
with  streaks  of  blood  in  it ;  erosions  about  the  os  uteri  which 
are  sensitive  to  touch,  bleed  easily,  sting  and  burn,  have  an  odor 
of  old  cheese. 

I  Hydrastis.  Tenacious,  thick,  ropy,  yellow  leucorrhcea. 
severe  erosion  of  the  cervix ;  constipation  with  hemorrhoids, 
and  dyspepsia,  with  a  faint  or  sinking  sensation  at  the 
stomach. 

'  Horn.  Jour,  of  Obst.,  May,  1886,  p.  231. 


244  ENDOMETRITIS. 

Kreosote.'  Yellow  leucoj'rhwa  with  gfeat  debility  (Carbo 
an.).  White  leucorrhoea  having  the  odor  of  green  corn  ;  sore- 
7iess,  smarting,  and  burning  between  the  labia  and  thighs,  with 
burning,  biting  pain;  violent  itching  of  the  vagina  and  labia; 
external  genitals  sometimes  swollen,  hot,  hard,  and  sore. 

I  Lycopodium  is  highly  recommended  by  Dr.  Leadam. 
Patient  looks  pale  and  sallow ;  complains  of  pressive  or  full 
headaches ;  sleeps  badly,  and  is  always  chilly ;  feels  full  after 
eating ;  "  bloating  "  or  distension  of  the  abdomen  from  accu- 
mulation of  gas ;  constipation  with  hard  stools ;  red  sediment 
in  the  urine.  There  seems  to  be  a  general  sluggishness  of  the 
muscular,  venous,  and  digestive  systems,  preventing  the  normal 
peristaltic  action  of  the  intestines  ;  there  is  dryness  and  burning 
in  the  vagina ;  darting  pains  in  the  uterine  region ;  coition  is 
painful.  The  leucorrhcea  may  be  like  milk  (Calc.  carb.,  coni., 
kreos., /«/r.,  sepia,  sulph.  ac),  bloody,  or  corroding. 

II  Mercurius.  The  solubilis  is  preferred  by  Dr.  Mathe- 
son  ^  for  superficial  erosion  of  the  os  uteri.  Dr.  Hughes  3  states 
that  mere.  cor.  is  his  favorite  remedy,  if  the  eroded  portion 
appears  deeply  excavated,  and  the  cervix  is  swollen  and  in- 
durated. Dr.  Ludlam^  recommends  mere.  iod.  for  endo-cer- 
vicitis  in  scrofulous  subjects,  with  erosion  of  the  os,  and 
enlargement  of  the  nabothian  glands.     It  is  especially  valuable 


^  Mrs. .     For  ten  years  she  suffered  from  a  frequent  and  copious  leu- 

corrhoeal  discharge,  staining  the  linen  yellow,  and  stiffening  it ;  worse  between  the 
menses  ;  vulva  a  little  irritated,  but  there  was  no  other  trace  of  disease.  Kreosote 
cured  her.  —  Dr.  Landry,  Bull,  de  la  Soc.  Med.  Horn,  de  France,  vol,  xii.  No.  5. 

^  Miss ,  aet.  25,  brunette.     Amenorrhoea  for  six  months,  from  chill,  when 

the  menses  returned  ;  cannot  lie  on  either  side;  constant  dull  pain  in  the  region  of 
both  ovaries,  and  inability  to  bear  pressure  there ;  urine  colorless  in  the  morning  ; 
brownish-yellow,  acrid  leucorrhcea.  She  was  given  kreosote  2ox.  before  each  meal. 
In  two  days  the  pains  were  less,  the  leucorrhcea  became  diminished,  less  acrid,  and 
she  could  lie  on  the  left  side  for  a  short  time.  She  then  received  kreosote  4X.  once 
a  day ;  the  morning  urine  now  became  of  a  normal  color.  In  fourteen  days  she 
could  lie  on  both  sides,  the  leucorrhcea  was  quite  gone,  also  the  pains  in  the  ovaries, 
and  she  remained  well.  —  Dr.  Prall,  Allgemeine  Horn.  Zeiiung,  vol.  xcii. 
No.  II. 

2  Dr.  Matheson,  Four  Lectures  on  the  Diseases  of  Women. 

3  Dr.  R.  Hughes,  Manual  of  Therapeutics,  vol.  ii.  p.  300. 
^  British  Jour,  of  Horn.,  1S84,  p.  302. 


THERAPEUTICS   OF  ENDOMETRITIS,    ETC.     245 

in  cases  of  gonorrhoea!  or  syphilitic  origin,  and  severe  erosions 
of  an  unhealthy  type ;  profuse,  greenish,  yellow,  or  purulent 
leucorrhxa,  worse  at  night ;  smarting,  corroding,  itching,  and 
inflammation  of  the  vagina.  It  is  a  superior  remedy  in  hyper- 
trophy of  the  uterus,  or  chronic  metritis. 

I  Nitric  acid.  This  was  a  favorite  remedy  of  Dr.  Jahr  ' 
for  flat,  superficial  erosions  on  the  cervix  (Thuja,  sepia),  resem- 
bling ulcerated  aphthas ;  erosions  resulting  from  syphilis,  dis- 
charging dirty  yellow  pus  ;  excrescences  on  the  os  uteri.  Dr. 
Leadam  recommends  its  persistent  use  in  alternation  with  sulphur 
at  long  intervals. 

I  Phosphorus  ought  to  be  a  good  remedy,  as  it  has  caused 
endometritis,^  but  there  are  very  few  reports  of  its  use.  The 
metises  are  too  early  and  too  scanty,  or  there  may  be  frequent 
and  profuse  metrorrhagia,  acrid  excoriating  leucorrhcea. 

I  Pulsatilla  is  one  of  the  best  remedies  for  leucorrhcea 
with  delayed  or  scanty  menses  ;  the  leucorrhcea  is  thick,  creamy, 
or  milky  (Calc.  carb.,  coni.,  sepia,  sulph.  ac),  with  swollen 
vulva,  painless;  acrid,  thin,  burning  (Alumina,  ars.,  coni., 
kreosote,  mere,  phos.)  ;  pressive  pain  toward  the  uterus,  with 
morning  nausea;  involuntary  micturition  at  night;  frequent, 
profuse  flow  of  urine  ;    dyspepsia. 

Rhus  tox.  has  been  recommended  for  erosions  of  the  cer- 
vix, having  a  raspberry  appearance,  probably  due  to  distension 
of  the  follicles.3 

1  Sepia.'^  Enlargement  of  the  uterus,  probably  from  venous 
engorgement ;  prolapsus,  with  jnuch  bearitig-down ;  great  dry- 
ness of  vulva  and  vagina,  which  are  painful  to  the  touch; 
leucorrhxa  yellow,  or  like   milk,  excoriating  {Alumina,  ars., 

'  Forty  Years'  Practice,  p.  179 ;  Diseases  of  Females,  p.  246. 

2  Hausmann,  Berl.  Bitr.  z.  Geburt.  u.  Gyn.,  Ed.  I.  s.  265. 

3  U.  S.  Med.  and  Surg.  Journal,  July,  1874. 

+  Girl,  jet.  5.  Pale,  emaciated,  no  appetite,  and  strength  rapidly  decreasing. 
For  fifteen  months  has  had  an  unceasing  and  terribly  exhausting  leucorrhcea.  The 
discharge  was  sometimes  thick,  and  of  a  yellowish  green  color,  sometimes  thin, 
and  always  very  profuse  ;  running  through  the  night-dress,  sheet,  and  down  into 
the  mattress  on  which  she  lay  at  night.  Sepia  4X.,  a  few  pellets  every  third  night, 
for  four  weeks, completely  cured  her. —  Dr.  Charles  Sumner,  A^.  K  State 
Trans.,  p.  314,  1871. 


246  ENDOMETRITIS. 

kreosote)  at  the  climacteric,  and  especially  before  the  menses  ; 
flat,  superficial  erosions  about  the  os ;  tendency  to  mucous 
catarrh  everywhere ;  constipation  and  piles ;  a  pale,  sallow 
complexion,  pimples  or  skin  eruptions  on  the  face  and  geni- 
tals ;  much  general  itching  of  the  skin.  It  is  very  serviceable 
in  chronic  inflammation  of  the  uterus.  Dr.  Dyce  Brown  uses 
the  twelfth  centesimal  with  great  confidence. 

I  Silicea.  Scrofulous  diathesis  ;  profuse,  thin,  acrid,  corro- 
sive (Ars.,  kreosote,  mere,  puis.),  or  purulent  leucorrhoea; 
constipation,  weakness,  and  sense  of  great  debility ;  sensitive- 
ness to  cold  air.  The  characteristic  headache  and  nervous 
symptoms  of  silicea  are  important  in  prescribing  this  remedy. 

I  Sulphur.  It  is  a  valuable  remedy  for  the  so-called 
chronic  metritis,  and  seems  to  reduce  the  venous  engorgement, 
by  stimulating  the  portal  circulation.  This  remedy  is  indicated 
by  the  general  rather  than  the  local  symptoms.  The  leucorrhoea 
is  profuse,  yellowish,  and  corrosive,  burning  in  the  vagina ;  the 
patient  is  melancholic,  irritable,  and  peevish,  complains  of  great 
mental  confusion,  vertigo,  weight  on  the  vertex,  rush  of  blood 
to  the  head ;  appetite  is  gone,  or  excessive,  fulness  and  pressure 
in  the  stomach  after  eating;  constipation,  or  early  morning 
diarrhoea ;  copious  and  frequent  urination  at  night ;  numb  sen- 
sations in  hands  and  feet ;  burning  of  the  soles  of  the  feet  at 
night. 

Thuja  was  recommended  by  Dr.  Hartraann  for  indurations 
and  readily  bleeding  excrescences  about  the  os  and  cervix  uteri ; 
but  Dr.  Jahr'  has  never  seen  the  least  benefit  from  it,  and 
speaks  highly  of  graphites  and  kreosote,  suggested  by  Dr. 
Wahle  of  Rome  for  the  same  condition.  Superficial,  aphthous 
erosions  about  the  os,  and  on  the  cervix  uteri.  Left-sided 
ovaritis,  worse  at  each  menstrual  period. 

Dr.  Jahr  states  that  he  has  found  the  following  reme- 
dies efficacious  for  catarrhal  leucorrhoea :  puis.,  sepia, 
sulph.,   calc,   cocc,    graph.,    lye.,    silicea.      Dr.   Clotar 

Forty  Years'  Practice,  p.  179. 


DIGEST  OF  REMEDIES  FOR  LEUCORRHCEA.     247 

Miiller '  recommended  especially  calc,  china,  mere,  nat. 
mur.,  phos.,  puis.,  sabina,  and  sepia.  He  also  wrote  the 
following  digest,  to  which  some  additions  have  been 
made  :  — 

Leucorrhcea  purely  in  consequence  of  chlorosis,  without 
any  granulations  or  excoriations.  —  Calc.  carb.,  china, 
ferrum,  nat.  mur.,  phos.,  puis.,  sepia. 

Leucorrhcea  with  marked  irritation,  erosions,  granula- 
tions, etc. — Ant.  tart.,  arg.  nit.,  bell.,  calendula,  hydras- 
tis,  iodine,  mere.,- sabina,  thuja. 

Leucorrhcea  with  cachectic  appearance,  and  organic  dis- 
ease of  the  uterus  and  jteighboring  organs.  —  Carbo  veg., 
ars.,  kreosote,  mere,  graph.,  sulph. 

Leucorrhcea  with  digestive  disturbances.  —  Nux  vom., 
phos.,  puis.  ;  if  also  hysterical  and  nervous,  cocc,  calc. 
carb.,  coff  ea,  lycop. 

Leucorrhcea  with  sexual  excitement,  lustful  crawling 
in  the  genitals.  —  Plat.,  china, 

Leucorrhcea  with  indifference  or  aversion  to  coitus.  — 
Causticum,  nat.  mur. 

Leucorrhcea  of  slimy,  white,  or  yellowish  mucus.  — 
Calc.  carb.,  natrum,  puis. 

Leucorrhcea  more  purulent.  —  China,  mere,  nit.  ac, 
nux  vom. 

Leucorrhcea,  thin  and  watery. — Alum.,  ars.,  graph., 
ferrum,  iodine,  sabina. 

Leucorrhcea,  thick  aitd fluid.  — Ars.,  mez.,  natr.,  sepia, 
zinc. 

Leucorrhcea,  excoriating,  biting.  —  Alum.,  ars.,  helo- 
nias,  iodine,  kreosote,  mere,  nit.  ae,  phos.,  puis.,  sepia, 
silie,  sulph. 

Leucorrhcea,  offensive.  —  Carbo  veg.,  kreosote,  nit. 
ae,  sabina. 

*  Horn.  Vierteljakrschrift,  p.  448,  i860. 


248  ENDOMETRITIS. 

Leucorrhoea,  bloody  slime,  or  like  meat-Juice.  —  Calc. 
carb.,  cocc.  2x.,  china,  kreosote,  lycop.,  nit.  ac. 

Leiicorrhcea,  white  and  milky.  —  Calc.  carb.,  ferrum, 
lycop.,  nat.  mur.,  puis.,  sabina,  silic,  zinc. 

Leiicorrhcea,  greenish.  —  Carbo  veg.,  kreosote,  mere, 
sabina,  sulph. 

Leucorrhoea,  yellowish. — Ars.,  kali  sulph.,  lycop., 
sepia. 

Leucorrhoea  before  the  menses.  —  Calc.  carb.,  phos., 
graph.,  carbo  veg.,  china,  sepia,  puis. 

Leucorrhoea  after  the  mejises.  —  Puis.,  alum.,  graph., 
silicea,  ruta,  calc.  carb. 

Lencorrhcea  instead  of  the  metises.  —  (Alumina),  ars. 
alb.,  china,  cocculus,  nux  mosch.,  phos.  (ruta  grav.), 
senecin,  sepia,  silicea. 

The  following  list  of  remedies  may  be  consulted  for 
further  study  :  — 

Alumina,  ammon.  carb.,'  arg.  nit.,  aurum,  bovista,^ 
calendula,  cannabis  sat.,^  carbo  animalis  and  veg., 
cauloph.,  ceanothus  am.,'^  cham.,  cicuta,  conium,  ferrum, 


'  Mrs.  B ,  set.  46.     Constant  feeling  of  weight  in  the  epigastrium,  worse 

after  food,  especially  meat ;  no  relish  for  food.  Menses  every  fortnight,  profuse, 
black,  coagulated;  profuse  tnilky  leucorrhoea,  with  itching  of  the  vulva,  and 
backache,  especially  before  and  after  the  menses;  urine  reddish,  and  flow  often 
interrupted.  Ammon.  carb.  4X.  cured  in  about  two  weeks.  —  Dr.  R.  M.  Theo- 
bald, Hahn.  Monthly.,  p.  332,  February,  1872. 

2  A  sense  of  enlargement  and  fulness  in  the  head,  in  an  obstinate  case  of 
leucorrhoea,  led  Dr.  Teste  to  give  bovista  with  success.  —  Brit.  Jour,  of  Horn,, 
p.  292,  1877. 

3  This  is  said  to  cure  infantile  leucorrhcea  with  the  greatest  certainty.  — 
Amerkati  Observer,  p.  539,  November,  1872. 

*  Constant  and  severe  pain  in  the  left  hypochondrium  of  more  than  two  years 
duration ;  also  pain  under  the  left  ribs,  with  yellow  leucorrhoea ;  menses  once  in 
two  weeks.  Ceanothus  amer.  6x.  prescribed.  The  pain  ceased  in  two  days,  and 
the  leucorrhoea  soon  after.  —  Dr.  J.  C.  Burnett,  Ho7n.  World,  p.  14,  Jan.  i, 


DIGEST  OF  REMEDIES  FOR  LEUCORRHCEA.    249 

gels,,  ham.,  hepar  s.,  hydrocotyle/  ignatia,  iodine,  ipecac,^ 
kali  carb.,  lach.,  HI.  tig.,  mag.  mur.,  nux  vom.,  Phyto- 
lacca, plati?ia,  puis.,  sabina,  secale,^  tarantula,'*  xantho- 
xylon. 

'  Highly  recommended  by  Dr.  Andouit  for  severe  erosions,  with  profuse  leu- 
corrhoea.  —  Allgemeine  Horn.  Zeitung^  also  Brit.  Jour,  of  Horn,,  p.  587,  1859. 

^  Dr.  Imbert  Goubeyre  has  given  it  a  limited  trial,  and  thinks  it  has  a  positive 
effect.  —  British  Jour,  of  Horn.,  p.  21,  1870. 

3  Mrs. .  Leucorrhoea  in  gushes  every  four  or  five  days ;  very  severe  bear- 
ing-down, dragging-out  feeling  in  the  lower  abdomen  ;  cannot  promptly  start  the 
flow  of  urine,  must  always  wait  a  few  minutes.  She  has  always  had  rheumatism. 
Secale  3X.  dil.  promptly  cured  her.  —  Dr.  J.  C.  Burnett,  Brit.  Jour,  of  Horn., 
p.  87,  1877-. 

^  Dr.  Nunez,  North  Am.  Jour,  of  Hom.,  vol.  xx.,  pp.  456  and  486. 


2 so  DESCRIPTION  OF  PLATE. 


Description  of  Plate. 

No.  I  shows  a  double  left-sided  laceration  of  the  cervix, 
extending  well  up  into  the  canal.  The  angles  are  drawn  apart 
to  obtain  a  better  view.  The  dotted  line  marks  the  external 
line  of  denudation,  and  extends  around  from  A  (original 
external  os)  back  to  A.  The  dark  shading  in  the  centre 
corresponds  to  the  erosion. 

No.  2  represents  the  cervix  drawn  to  one  side,  with  silk 
sutures  inserted.     A  marks  the  external  os. 

No.  3  was  photographed  from  a  very  severe  double  laceration 
of  the  cervix,  extending  beyond  the  vaginal  junction.  The 
lips  are  held  apart  by  tenacula,  to  show  the  erosion,  which 
is  shaded  dark. 

No.  4  and  No.  j  are  more  common  forms  of  bi-lateral 
laceration,  with  the  patient  in  Sims'  position. 

No.  6  was  photographed  from  a  bad  case  of  bi-lateral 
laceration,  a  little  deeper  on  the  left  than  the  right  side.  As 
in  the  others,  the  dark  shading  corresponds  to  the  erosion. 

No.  7  shows  No.  6  with  silver  wires  in  situ. 

No.  8,  the  same  as  No.  /,  with  cervix  drawn  one  side  to 
show  the  sutures  laterally. 


EROSION,  ETC.,   OF   THE   CERVIX   UTERI.    25 1 


CHAPTER    XVII. 

EROSION,    ULCERATION,    AND    LACERATION    OF 
THE    CERVIX    UTERI. 

IN  connection  with  endometritis,  it  may  not  be  out  of 
place  to  describe  the  above  lesions,  which  so  often 
accompany  it,  and  are  of  so  much  practical  importance. 
This  has  seemed  all  the  more  necessary,  as  so  many 
practitioners  are  not  aware  of  the  relation  of  erosion 
of  the  cervix,  laceration  of  it,  endometritis,  and  leucor- 
rhoea,  to  one  another.  Many  do  not  make  a  distinction 
between  erosion  and  ulceration.  A  genuine  ulcer  of 
the  cervix  is  scarcely  ever  seen,  except  in  malignant 
disease;  and  the  "ulcer  on  the  womb,"  which  strikes 
terror  to  the  heart  of  the  patient,  and  makes  the  case 
too  often  a  profitable  one  to  the  doctor,  is  merely  an 
abrasion  of  epithelium,  more  or  less  severe.  Its  real 
name  is  erosion.  This  may  be  so  severe  as  to  have  a 
red,  angry  appearance,  with  tufts  of  villi  on  the  surface, 
feeling  rough  or  slightly  granular  to  the  touch ;  the  fol- 
licles are  enlarged,  and  in  some  places  have  dried  up, 
leaving  chalk-like  or  cheesy  granules  on  the  surface. 

It  may  be  laid  down  as  a  rule,  with  few  exceptions, 
that,  where  severe  erosio7i  is  present,  there  is  also  a  lacer- 
atioji  of  the  cervix  as  the  priinary  cause.  The  erosion 
may  temporarily  heal,  but  is  almost  sure  to  return  if 
the  laceration  be  not  properly  closed  by  an  operation. 
Some  of   the  effects  of    laceration  are  shown  in  the 


252      EROSION,   ETC.,    OE   THE   CERVIX   UTERI 

following  diagrams,  which  also  serve  to  explain  why  it 
is  not  always  easy  to  make  a  diagnosis. 


Fig.  67. 

Diagram  of  uterus.     The  line  of  lacerati  .r.,  eg,  which  may  be  uni-  or  bi-lateral  ;    v,  v, 
vaginal  walls;  A,  diagram  of  cervix  as  seen  with  a  speculum. 


Fig.  68. 


In  this  diagram,  the  lacerated  surfaces,  e,  g,  have  flattened  out  against  the  vaginal  walls, 
V,  v;  they  are  eroded,  and  the  follicles  enlarged.  B,  speculum  view  of  the  cervix» 
the  shading  representing  the  area  of  laceration.     Compare  Fig.  67. 


LACERATION  OF  THE    CERVIX   UTERI.       253 


Fig.  69. 

Section  of  uterus  showing  laceration  of  the  cervical  canal  extending  to  the  line  Ik ;  C, 
speculum  view  of  cervix  with  large  irregular  os  uteri.     Compare  Figs.  67  and  68. 


Fig.  70. 

The  same  as  C,  showing  the  cervical  hyperplasia,  and  rolling-out  of  the  cervical  raucous 
membrane,  the  dotted  line  representing  the  normal  contour. 


When  a   laceration    of   the    cervix   takes   place,  the 
uterus  is  enlarged,  heavy,  and  sinks  down  in  the  pelvis 


254      EROSION,   ETC.,   OF  THE   CERVIX  UTERI. 

so  as  to  drag  somewhat  on  the  ligaments  by  which  it  is 
suspended.  As  the  cervix  is  torn  and  its  outer  surface 
divided,  the  tension  from  above  is  unequally  distributed, 
and  the  lips  gape  a  little,  like  a  split  celery-stalk.  The 
posterior  lip  may  catch  on  the  sacral  wall,  and  the  more 
the  heavy  uterus  sinks  in  the  pelvis,  the  more  the  lacer- 
ated surfaces  and  the  cervical  canal  are  flattened  out 
against  the  posterior  vaginal  wall.  The  blood-vessels 
in  the  cervix  may  be  somewhat  constricted  in  conse- 
quence ;  there  is  congestion  and  hypertrophy  of  the 
cervical  lips,  and  involution  of  the  entire  uterus  is 
retarded.  The  capillaries  are  engorged,  and  serum 
poured  forth.  The  epithelial  layer  is  softened  and  cast 
off,  aided  by  the  friction  against  the  vagina.  The  folli- 
cles are  also  involved,  their  excretory  ducts  occluded, 
and  the  secretion  collecting  in  the  interior  distends  them 
with  a  peculiar  pearly  lustre.  They  may  burst,  and 
discharge  the  contents ;  or  the  latter  may  dry  up,  leav- 
ing a  whitish,  cheesy  residue,  looking  like  a  particle  of 
chalky  concretion  just  beneath  the  surface. 

It  is  evident  that  so  long  as  the  lacerated  surfaces  are 
continually  irritated  by  constant  friction  against  the 
vagina,  no  permanent  cure  will  take  place.  The  red, 
raw,  angry-looking  surface  may  be  healed  temporarily 
by  treatment,  but  the  same  condition  is  almost  always 
reproduced  by  the  same  causes.  Nature  attempts  to 
cure  it  by  uniting  the  wound  ;  and  in  consequence  we 
find  plugs  of  hardened  or  so-called  cicatricial  (?)  tissue 
in  the  angles,  which  are  the  source  of  a  large  amount 
of  direct  or  reflex  irritation.  The  latter  may  be  in  the 
form  of  various  neuralgias  in  different  parts  of  the  body, 
without  unusual  pelvic  symptoms  pointing  to  local 
trouble.  Leucorrhoea  is  frequently  present.  On  ex- 
amination, the  angles  of  the  laceration  are  sensitive,  the 
erosion  has  a  soft  velvety  feeling,  the  follicles  feel  like 


DIAGNOSIS  AND  SEQUELS.  255 

bird-shot  beneath  the  surface,  and  often  cicatricial  bands 
extend  to  the  areolar  tissue.  Localized  cellulitis  near 
the  angles,  and  sub-involution,  are  often  present.  Be 
sides  sore  aching  pains  in  the  pelvis,  there  are  the 
symptoms  arising  from  various  complications,  and  not 
infrequently  reflex  neuralgia. 

The  reason  why  so  many  cases  of  laceration  of  the 
cervix  are  mistaken  for  erosions  or  so-called  ulcerations 
is,  that  most  practitioners  use  a  tubular  or  bivalve  specu- 
lum ;  this  distends  the  vaginal  vault,  and  stretches  the 
cervical  lips  apart  so  that  the  eroded  surfaces  appear  to 
lie  in  nearly  the  same  plane,  and  bear  a  close  resem- 
blance to  a  granulating  ulcer  (see  Fig.  68,  B).  The 
Sims'  speculum  is  the  only  one  giving  a  view  of  the 
cervix  without  disturbing  the  relation  of  the  parts. 

The  presence  of  a  laceration,  if  it  is  not  felt  by  the 
examining  finger,  can  be  readily  ascertained  by  hooking 
two  uterine  tenacula  into  the  lips  of  the  cervix,  and 
bringing  them  together,  when  the  eroded  surfaces  will 
roll  into  partial  apposition,  and  the  line  of  laceration 
appear  on  the  outer  margin  of  the  cervix. 

The  SequelcE  of  cervical  lacerations  are  sometimes 
serious,  though  not  in  every  case.  It  has  been  truly 
said,  that  there  is  scarcely  any  portion  of  the  body 
where  comparatively  slight  lesions  may  produce  so 
much  suffering  as  in  the  pelvic  organs.  Perhaps  the 
most  important  of  the  results  of  laceration  of  the  cervix 
is  the  increased  susceptibility  to  epithelioma  of  the 
cervix,  from  the  continued  irritation  of  the  raw  granular 
surfaces.  The  latter  has  been  so  marked,  that  distin- 
guished specialists  with  an  unusually  large  experience 
have  mistaken  it  for  epithelioma. 

Besides  the  local  symptoms  already  described,  there 
are  hysterical  manifestations,  neuralgias,  sub-involution, 
menstrual  derangements,  ansemia,  and  even  a  partial  loss 


256      EROSION,  ETC.,    OF  THE   CERVIX  UTERI 

of  mental  power.  The  only  remedy  is  an  operation 
which  will  remove  the  plugs  of  hardened  (cicatricial) 
tissue,  and  restore  the  cervix  as  nearly  as  possible  to 
its  original  condition.  Not  every  case  needs  it,  nor  does 
the  necessity  for  an  operation  depend  entirely  upon  the 
extent  of  the  lesion.  A  small  laceration,  with  a  large 
amount  of  hardened  tissue  in  the  angle,  often  gives  rise 
to  more  severe  symptoms  than  deep  lacerations  with 
less  cicatricial  (i*)  tiss'ue. 

The  necessity  for  an  operation  depends  upon  the 
symptoms  remaining  after  the  cellulitis  has  subsided, 
and  the  endo-cervicitis  healed  so  far  as  possible,  except 
in  cases  where  there  is  a  family  history  of  malignant 
disease.  In  the  latter  instance,  the  operation  should 
always  be  performed  to  remove  any  possible  focus  of 
irritation  for  the  development  of  epithelioma. 

If  there  are  troublesome  symptoms  remaining,  such 
as  pain,  leucorrhoea,  headaches,  neuralgia,  menorrhagia, 
etc.,  after  a  careful  selection  of  remedies,  combined  with 
local  treatment,  an  operation  is  advisable,  more  espe- 
cially if  the  patient  dates  the  trouble  from  some  par- 
ticular confinement. 

Two  questions  come  up  for  consideration  in  connec- 
tion with  this  operation  :  first,  whether  it  entails  ste- 
rility ;  and,  second,  if  not,  the  possibility  of  recurrence 
in  a  subsequent  pregnancy.  Much  has  been  written, 
and  statistics  collected,  to  decide  the  question  if  possi- 
ble. So  far,  there  is  reason  to  believe  it  favors  rather 
than  prevents  child-bearing,  more  especially  in  those 
cases  where  a  deep  cervical  laceration  destroys  the  nor- 
mal resistance  of  the  inferior  segment  of  the  uterus, 
and  the  latter  expands  with  the  growing  ovum,  allowing 
it  to  escape  prematurely.  It  is  not  unlikely  that  an 
expert  operator  might  succeed  in  constructing  a  very 
narrow  cervical  canal  which  would  materially  diminish 


TREATMENT  FOR  LACERATION.  257 

the  chances  of  conception.  During  normal  labor,  the 
cervix  should  not  be  meddled  with  by  stretching  it  in 
any  way.  This  is  a  common  cause  of  laceration,  though 
the  lesion  is  unavoidable  in  many  cases. 

Careful  observers  believe  that  the  slight  cicatricial 
tissue  in  the  line  of  union  is  absorbed  within  six  months 
afterward,  and  does  not  cause  rigidity  of  the  cervix. 
This  is  probably  an  instance  of  the  alterative  effect 
which  commonly  follows  the  operation,  as  an  enlarged 
uterus  not  infrequently  becomes  smaller,  apparently  as 
the  result. 

Should  a  laceration  be  discovered  during  the  lying-in 
period,  it  might  heal  spontaneously  if  kept  cleansed  by 
vaginal  douches  of  warm  calendulated  water,  but  closure 
by  suture  should  not  be  attempted  till  after  the  period 
of  involution  has  passed,  i.e.,  not  earlier  than  three 
months  after  labor.  If  the  lesion  has  existed  for  some 
time,  and  is  complicated  by  pelvic  cellulitis,  endo-cer- 
vicitis,  granular  degeneration  of  the  cervix,  etc.,  careful 
preparatory  treatment  is  essential  to  success.  It  is 
important  that  the  congestion  and  erosion  of  the  cervix 
be  reduced  as  much  as  possible  ;  and  all  local  inflamma- 
tion and  soreness  about  the  cervix  must  have  disap- 
peared before  it  is  advisable  to  operate  on  the  laceration, 
i.e.,  perform  trachelorrhaphy,  or  hystero-trachelorrhaphia 
as  it  has  been  more  properly  termed.  The  preparatory 
treatment  is  therefore  the  same  as  for  endometritis  and 
inflammation  of  the  pelvic  cellular  tissue  and  perito- 
neum, to  which  the  reader  is  referred. 

There  is  very  little  risk  to  life  ;  in  over  three  thousand 
cases,  ten  deaths  occurred,  and  these  when  the  operation 
was  less  understood  than  at  the  present  time.  The  per- 
centage of  failures  to  secure  union  is  larger  in  hospital 
than  private  practice,"  which  seems  to  show  that  it  is  for 

'  Dr  B.  H.  Wells,  American  Jomnal  of  Obstetrics,  June,  1SS4. 


258      EROSION,  ETC.,   OF  THE   CERVIX  UTERI 

the  advantage  of  the  patient  to  have  the  operation  per- 
formed at  home  or  in  a  private  house  rather  than  in  a 
hospital. 

HYSTERO-TRACHELORRHAPHIA,  OR  THE  OPERATION  FOR 
THE  CURE  OF  A  LACERATED  CERVIX  UTERI  (eMMET's 

operation). 

In  some  cases  where  women  object  to  ether,  or  the 
presence  of  renal  or  cardiac  disease  counter-indicates 
it,  this  operation  can  be  performed  with  or  without  a 
six-per-cent  solution  of  cocaine,  as  the  cervix  is  not 
composed  of  very  sensitive  tissue.  The  cocaine  can  be 
applied  freely  before  the  operation,  with  a  camel's-hair 
pencil,  and  at  intervals  of  five  or  ten  minutes  during  it 
if  necessary.  Freshening  the  surfaces  will  not  be  felt, 
but  the  insertion  of  the  needles  is  sometimes  painful. 
As  a  rule,  it  is  better  to  give  ether. 

About  half  an  hour  before  the  operation,  the  patient 
should  undress,  put  on  a  vest,  nightgown,  and  stockings, 
and  then  take  a  vaginal  douche  of  six  quarts  of  hot 
(ii2°)  mercurialized  (i  14000)  water  while  lying  on  her 
back.  This  not-  only  cleanses  the  vagina,  but  also 
diminishes  the  amount  of  blood  in  the  veins  and  capil- 
laries, and  thus  lessens  oozing.  The  rectum  should  be 
emptied  by  an  enema. 

While  this  is  being  done,  the  room  where  the  opera- 
tion will  take  place  is  prepared  in  the  following  man- 
ner :  Place  a  table  (a  kitchen-table  does  nicely)  about 
two  by  four  feet,  in  a  good  light,  with  the  foot  of  it 
towards  the  window,  and  raised  a  couple  of  inches  on 
a  piece  of  plank  or  a  couple  of  bricks ;  cover  it  with  a 
couple  of  folded  blankets ;  a  waterproof  over  them,  at 
the  foot,  and  put  a  pillow  at  the  head.  Near  the 
latter  place  a  slop-pail,  and  a  small  stand  with  a  couple 
of  wash-bowls  and  pitchers  of  hot  and  cold  water  for 


OPERATION  FOR  LACERATION.  259 

washing  sponges.  The  latter  are  first  cleansed  in  one 
bowl  of  carbolized  (three-per-cent)  water,  and  rinsed  in 
the  second  bowl  of  water  carbolized  in  the  same  way, 
taking  care  to  squeeze  them  quite  dry  before  they  are 
passed  to  the  second  assistant.  If  the  operator  prefers, 
a  .solution  of  corrosive  sublimate  or  the  bin-iodide  of 
mercury  (i  :400o)  can  be  substituted  for  the  solution 
of  carbolic  acid. 

Another  small  stand  is  placed  near  the  foot,  and  to 
the  right  of  the  operating  table.  The  instruments 
to  be  used  are  put  for  a  few  minutes  in  a  five-per-cent 
solution  of  carbolic  acid,  wiped  dry,  and  laid  on  a  clean 
towel  which  covers  the  small  table.  It  is  well  to  have 
them  grouped  together  for  convenience ;  i.e.,  tenacula 
in  one  group,  scissors  in  another,  and  those  used  in 
applying  the  sutures  in  a  third  group,  etc. 

The  operation  about  to  be  described  is  that  of  its 
originator,  and  the  method  universally  employed  in 
New  York.  It  is  more  difficult,  and  requires  more 
time,  than  the  method  of  placing  the  patient  in  the 
exaggerated  lithotomy  position,  freshening  with  the 
knife,  and  using  curved  needles  with  silk  sutures.  I 
have  tried  both,  and  prefer  the  former  method.  The 
chief  objections  to  the  latter  are,  liability  to  excite 
pelvic  inflammation  by  dragging  on  adhesions  or  sites 
of  previous  cellulitis,  weakening  of  the  uterine  liga- 
ments, and  a  remote  possibility  of  causing  hsematocele 
by  the  tearing-away  of  an  adhesion,  or  rupture  of 
varicose  veins  ^  in  the  broad  ligaments  ;  its  advantages 
are  the  ease  and  rapidity  with  which  the  operation  can 
be  performed. 

It  is  a  good  plan  to  explain  to  each  assistant,  if 
inexperienced,  the  details  of  what  is  expected  of  him, 

'  Dr.  Emmet  records  a  very  serious  case  of  haematocele  caused  by  traction  on 
the  cervix,  in  his  Principles  and  Practice  of  Gynaecology,  p.  227,  1SS4. 


26o  .    EROSION,   ETC.,    OF   THE   CERVIX   UTERI 

names  of  instruments,  etc.  This  advice  may  seem  super- 
fluous ;  but  the  rapidity  and  success  of  an  operation 
depend  largely  upon  the  detail  of  preparations,  and  the 
knowledge  as  well  as  experience  of  the  assistants. 
Much  of  the  time  occupied  by  an  operation  is  often 
spent  by  the  operator  having  to  do  his  own  sponging, 
waiting  for  instruments,  etc.,  instead  of  having  every 
thing  at  hand  the  instant  it  may  be  required. 

There  should  be  six  assistants,  arranged  in  the  fol- 
lowing manner ;  but  it  is  possible  to  get  along  with  half 
that  number :  — 

The  first  one  administers  ether. 

The  second  stanjis  to  the  right  of  the  table,  and, 
bending  over  the  patient,  sponges ;  he  has  also  charge 
of  the  tenaculum  to  steady  the  uterus  in  the  left  hand, 
uses  the  counter-pressure  hook  and  wire  scissors.  He 
must  always  watch  the  field  of  operation,  passing  .soiled 
sponges  over  his  shoulder,  and  picking  up  fresh  ones 
from  a  towel  laid  over  the  patient  at  his  right. 

The  third  assistant  sits  at  the  right  of  the  operator, 
watching  him  closely,  and  anticipating  him  in  the 
choice  of  instruments  by  holding  the  proper  one  where 
it  can  be  seized  at  once,  receiving  in  return  the  one 
previously  used. 

The  fourth  assistant  holds  the  speculum,  and  raises 
the  upper  labium  with  the  left  hand.  It  is  of  great 
importance  to  keep  the  speculum  in  the  precise  position 
given  by  the  operator. 

The  fifth  assistant  thoroughly  washes  the  sponges 
without  removing  them  from  the  holders,  and  places 
them  with  the  handles  toward  the  operator  on  the  upper 
thigh  of  the  patient  ;  or,  better,  hands  them  to  the 
second  assistant. 

The  sixth  assistant  does  errands  about  the  room,  and 
helps  wash  and  hand  the  sponges. 


OPERATION  FOR  LACERATION. 


261 


The   following    instruments    will    be    found    neces- 
sary :  — 


Fig.  71, 

I  broad,  short,  and  flat  Suns'  speculum. 


I  Emmet's  tenaculum. 


Fig.  72^ 


I  Sims'  tenaculum. 


Fig    73. 


codman  &  shtjktlefp,  boston. 
Fig.   74. 


1 


I  heavy  tenaculum  of  solid  steel,  short  hook  and  heavy  shank. 
I  long  mouse-toothed  forceps. 


CODMAN  &   SHTTETLEFF,   BOSTON. 


Fig.  75. 


I  pair  straight  sharp-pointed  scissors,  slightly  curved  on  the 
flat  (Dawson's). 


262     EROSION,   ETC.,    OF  THE   CERVIX   UTERI 


Fig.  76 


I  pair  Emmet's  cervix  scissors,  curved  for  the  right  hand. 


CODMAN  &   SHTJRTLEFP,   BOSTON. 


Fig.  77. 


T  counter-pressure  hook. 

I  Sims'  needle-forceps. 

6  Emmet's  needles,  latest  pattern,  sizes  varying  from  %  in. 
to  iK  in.  long,  threaded  by  passing  the  ends  of  a  piece 
of  fine  braided  and  waxed  silk  ligature,  sixteen  inches 
long,  through  the  eye  of  the  needle,  in  opposite  direc- 
tions. The  needle  and  ends  of  the  silk  are  twisted  a 
little,  to  prevent  the  loop,  which  is  about  six  inches  long, 
from  slipping  out.  A  neat  way  to  prevent  tangling  of 
the  threads  is  to  baste  them  coarsely  through  a  strip  of 
chamois-skin. 

12  pure  annealed  silver  wires  (No.  27),  twelve  inches  long, 
with  half  an  inch  of  one  end  of  each  bent  at  a  sharp 
right  angle,  to  hook  in  and  bend  close  down  on  the  silk 
loop. 


Fig.  78. 


I  Emmet's  wire-twister. 


OPERATION  FOR  LACERATION. 


263 


I  Sims'  shield. 

I  pair  of  wire  scissors. 


Fig,  79. 


^'" ■—■'    niiBfiliifi I  irantirmiit 


I  Uterine  sound. 


Fig.  80. 


F.G.0TTQ-SOWS.N.Y. 


Fig.  81. 


6  solid  sponge-holders,  in  which  are  firmly  fastened  as  many- 
very  small,  fine,  aseptic  sponges ;  and  an  equal  number 
of  sponges  in  the  clean  carbolized  water. 

It  is  better  to  etherize  the  patient  in  an  adjoining 
room,  bring  her  in,  and  place  her  on  the  table  in  Sims' 
position.  A  towel  is  folded  from  before  backwards,  over 
each  thigh  and  buttock.  The  speculum  is  inserted  so 
as  to  properly  expose  the  cervix,  and  given  to  the 
assistant  to  hold.  The  cervix  is  now  seized  in  the 
median  line,  with  the  solid  tenaculum,  on  the  anterior 
lip  (at  K,  Fig.  82),  and  drawn  a  little  forward,  so  as  to 
put  the  tissues  somewhat  on  the  stretch,  and  obtain  a 
better  view  of  the  torn  surfaces ;  the  posterior  lip  is 
seized  with  a  second  tenaculum,  and  the  two  lips  are 
brought  together  to  ascertain  the  amount  of  denudation 
necessary  to  obtain  a  symmetrical  cervix. 

The  solid  tenaculum  is  then  given  to  the  second 
assistant,  who  holds  it  in,  and  thus  steadies,  the  uterus 
with   his   left  hand   while   he   sponges   with   his   right. 


26^    EROSION,   ETC.,    OF   THE   CERVIX   UTERI. 

The  operator  now  takes  up  a  bit  of  tissue  on  the  lower 
side  at  a  point  corresponding  and  opposite  to  G,  Fig.  82, 
with  Emmet's  fine  tenacukmi,  or,  if  the  tissues  are  soft 
and  friable,  with  the  long  mouse-toothed  forceps  in  his 
left  hand,  and  denudes  with  the  scissors  (Dawson's)  a 
thin  continuous  strip  up  to  the  angle  F,  which  is  met 
by  a  corresponding  strip  on  the  posterior  lip.  The  sharp 
curved  scissors  are  often  useful  in  denuding  the  angle. 


Fig.  82. 

Diagram  of  a  bi-lateral  laceration  of  the  cervix,  with  the  anterior  (A)  and  posterior  (B)  lips 
drawn  apart,  the  shape  of  the  denuded  strips  with  the  sutures  inserted  in  the  upper  one; 
KK,  undenuded  strip  left  to  form  the  cervical  canal;  FF,  angle  of  laceration,  and 
divergence  of  the  lips;  G,  denuded  strip;  ee,  first  suture  inserted  at  the  angle;  dd, 
second  suture;  fc  and  ^^,  also  sutures;  H,  cervical  canal. 

Here  the  dissected  strips  must  not  be  pulled  on  hard 
while  the  scissors  are  cutting  behind  them,  on  account 
of  stretching  and  removing  much  more  than  is  neces- 
sary. 

All  enlarged  follicles  must  be  entirely  removed,  as 
well  as  hardened  pieces  of  tissue  at  the  angle.  The 
latter,  or  supposed  cicatrices,  are  seldom  as  large  as 
peas,  and  the  operator  should  not  feel  it  necessary  to 


OPERATION  FOR  LACERATION.  265 

excise  a  large  section  on  account  of  "the  cicatrix." 
The  area  of  denudation,  which  is  shown  in  Fig.  82, 
ought  not  to  extend  far  out  on  the  external  mucous 
membrane  of  the  cervix  ;  and  a  strip  about  three-six- 
teenths of  an  inch  wide  (K  K)  must  be  left  for  the 
cervical  canal,  a  little  larger  at  the  outer  ends  so  as  to 
avoid  too  small  an  external  os  after  union  and  shrink- 
ing of  the  tissues.  A  similar  strip  is  then  removed  in 
like  manner  from  the  upper  side  of  the  cervix.     It  is 


Fig.  83. 

Diagram  of  the  cervix  after  the  lips  are  drawn  together  and  the  wires  twisted.     Letters 
same  as  in  Fig.  8i. 

important  to  bear  in  mind  that  the  strips  on  the  an- 
terior and  posterior  lips  are  corresponding  halves,  and 
must  be  symmetrical,  the  anterior  with  the  posterior 
portion,  in  order  to  obtain  good  union. 

If  the  laceration  is  on  one  side,  only  that  side  is 
denuded.  The  question  of  uni-  or  bi-lateral  laceration 
is  easily  settled  by  passing  a  sound  in  the  uterus,  and 
holding  it  in  the  median  line,  and  the  extent  of  lacera- 
tion on  one  or  both  sides  of  the  sound  at  once  makes 
the  diagnosis.  Some  allowance  must  be  made  when 
lateral  displacement  is  present. 


266    EROSION,   ETC.,    OF   THE    CERVIX   UTERI. 

There  is  little  use  in  waiting  and  sponging  for  bleed- 
ing to  cease.  If  there  is  some  point  which  bleeds  freely, 
it  can  be  seized  with  artery  forceps  (Pean's)  till  the 
wires  are  in  ready  for  twisting.  The  best  way  is  to 
proceed  at  once  to  insert  the  sutures,  beginning  at 
the  angles,  and,  if  the  laceration  be  bi-lateral,  put  in  the 
suture  first  on  one  side,  then  on  the  other;  for,  if  all 
the  wires  are  inserted  on  one  side  first,  there  is  less 
room  to  put  in  the  others  on  the  opposite  side.  For 
this  reason,  unilateral  tears  are  more  difficult  to  suture 
than  laceration  of  both  sides  of  the  cervix. 

The  first  suture  is  at  a  level,  or  a  trifle  above  the 
denuded  angle.  When  this  is  tightened  or  drawn  upon, 
it  rarely  fails  to  control  the  bleeding.  The  third  assist- 
ant bends  the  silver  wire  close  down  upon  the  loop 
attached  to  the  needle  (three-fourths  to  one  inch  long), 
puts  the  needle  in  the  needle-forceps,  and  hands  it  to 
the  operator.  It  is  inserted  about  a  quarter  of  an  inch 
from  the  margin  of  the  wound,  and  passed  straight 
through  nearly  to  the  centre  of  the  undenuded  strip 
for  the  cervical  canal.  As  the  point  is  seen  to  emerge 
on  the  surface,  the  second  assistant  presses  on  the 
cervix  at  that  place  with  the  counter-pressure  hook,  and 
the  needle  is  pulled  through  with  the  needle-forceps. 
It  is  again  inserted,  and  made  to  emerge  at  correspond- 
ing points  on  the  other  lip.  The  loop  and  wire  are 
then  held  taut  in  the  hands,  and  the  wire  is  made  to 
pass  through  by  a  quick  to-and-fro  motion.  One  end 
of  the  wire  is  bent  over  and  twisted  a  little  around 
the  other  end,  and  slipped  up  within  two  inches  of  the 
cervix,  while  the  free  end  is  caught  by  the  fingers  of 
the  nurse,  if  on  the  upper  side  ;  if  the  lower,  it  is 
passed  beneath  the  lower  edge  of  the  speculum. 

Each  suture  is  inserted  in  this  way,  with  a  space  of 
three-sixteenths  of  an  inch  between  them  ;  three  on  a 


OPERATION  FOR  LACERATION.  267 

side  are   usually  sufificient ;   a  little   puckering  of   the 
edges  can  be  remedied  by  superficial  silk  sutures. 

The  object  of  passing  the  needle  through  each  lip 
separately  is  to  secure  greater  accuracy  of  adaptation. 
A  common  mistake  is  to  pass  the  needle  near  the 
denuded  surface ;  the  result  is,  when  the  suture  is 
tightened  it  puckers  the  surfaces  together  like  the  run- 
ning-string in  a  bag,  and  there  is  only  external  union, 
leaving  a  dilated  cervical  canal  in  which  the  secretions 
collect,  and  the  patient  derives  little  if  any  benefit  from 
the  operation.  The  same  objections  apply  to  the  curved 
needle,  which  necessarily  passes  in  a  curved  direction, 
and  drawing  on  the  suture  tends  to  force  and  pucker 
the  tissues  round  a  common  centre  more  than  when 
the  straight  needle  is  used  in  the  above  manner. 

The  difficulty  in  introducing  the  first  sutures  at  the 
extreme  upper  margin  of  the  angles  arises  from  lack  of 
space  to  use  the  needle  and  its  holder.  This  can  be 
obviated  by  passing  two  needles,  one  through  each  lip, 
from  the  cervical  canal  out  to  the  surface  where  it  can 
be  easily  seized.  One  loop  is  passed  through  the  other, 
the  latter  is  drawn  out  through  the  lip  carrying  the 
former  loop  with  it,  which  now  extends  through  both 
lips ;  a  silver  wire  is  then  easily  bent  down  in  it,  and 
drawn  through  as  before. 

After  the  wires  are  all  in  place,  the  lips  of  the  cervix 
are  gently  separated,  and  all  coagula  or  bits  of  fibrine 
carefully  sponged  away. 

The  sutures  are  fastened  in  the  following  manner : 
Both  ends  of  the  wire  at  the  angle  are  seized  by  the 
twister,  about  two  inches  from  the  cervix,  and  the  long 
free  end  cut  off  by  the  second  assistant.  Holding 
the  wires  by  the  twister,  the  operator  kinks  them 
down  together  immediately  over  the  proposed  line  of 
union   by   the  tenaculum,  slips  the    shield    over   them 


268    EROSION,   ETC.,    OF  THE   CERVIX  UTERI. 

close  to  the  cervix,  bends  the  wire  down  sharply  over 
the  shield,  and  twists  till  the  twist  of  the  two  wires 
meets  at  the  edge  of  the  wound,  and  removes  the  shield. 
A  fine  tenaculum  is  now  slipped  beneath  the  wire  loop, 
and  draws  it  out  slightly  where  it  enters  the  cervix  on 
either  lip ;  this  diminishes  the  tension  and  danger  of 
cutting  out  at  these  points.  The  twisted  end  is  bent 
close  down  on  the  cervix  at  right  angles  to  the  wound, 
and  cut  off,  leaving  an  end  half  an  inch  long  which  will 
not  prick  into  adjacent  tissues.  If  the  latter  are 
blanched  about  the  wire,  it  is  too  tight,  and  must  be 
loosened  by  untwisting. 

Each  suture  is  fastened  in  this  way ;  the  margin  of 
the  wound  being  held  by  tenacula,  if  necessary,  to 
secure  perfect  adaptation,  or  prevent  rolling-in  of  the 
margins. 

Finally  the  sound  is  passed,  to  be  sure  that  the  cer- 
vical canal  is  pervious,  the  uterus  placed  in  anteversion, 
retained  if  necessary  by  a  small  tampon  smeared  with 
vaseline,  and  the  patient  put  to  bed.  She  should  be 
kept  as  absolutely  quiet  as  possible  for  forty-eight  hours, 
so  as  to  secure  primary  union.  On  no  account  must 
she  rise  or  sit  up  in  bed  for  the  first  few  days.  The 
urine  or  faeces  can  be  passed  in  a  bed-pan.  Night  and 
morning,  as  well  as  after  each  micturition,  a  vaginal 
douche  should  be  given  of  two  quarts  of  warm  water 
and  one  tablespoonful  of  the  non-alcoholic  extract  of 
calendula ;  some  surgeons  prefer  hydrastis  to  the  calen- 
dula. The  night  and  morning  douches  can  be  dispensed 
with  after  the  fourth  day,  if  there  be  no  discharge.  It 
is  not  uncommon  to  have  very  slight  oozing  for  the 
first  twenty-four  hours,  and  on  the  third  or  fourth  day  a 
reddish  discharge  may  appear  for  a  short  time,  similar 
to  the  menses.  This  need  cause  no  alarm,  and  very 
seldom  interferes  with  union. 


OPERATION  FOR  LACERATION.  269 

There  is  scarcely  ever  any  pain  or  rise  of  tempera- 
ture (above  99°)  after  the  operation  ;  indeed,  it  may  be 
said,  there  are  few  if  any  operations  known  which  so 
often  give  as  much  relief  with  as  little  pain  and  risk  as 
trachelorrhaphy.  The  great  risk  in  properly  prepared 
cases  is  wounding  the  circular  artery  by  cutting  too 
deeply  in  the  angles.  The  best  remedy  for  this  is  to 
pass  a  deep  suture  above  the  angle  and  twist  it  up. 

If  the  laceration  was  deep,  and  required  seven  or 
eight  sutures,  they  should  remain  ten  days  ;  otherwise, 
they  can  be  removed  on  the  eighth  day.  For  this  pur- 
pose the  patient  is  again  placed  in  Sims'  position,  the 
speculum  inserted,  the  cervix  brought  a  little  forward, 
and  steadied  by  a  tenaculum  inserted  in  the  posterior 
surface  of  the  posterior  lip.  The  wire  twist  is  gently 
raised  with  the  forceps  till  the  shining  loop  is  seen, 
which  is  cut  with  the  wire  scissors  near  its  insertion  in 
the  cervix  ;  it  is  then  withdrawn  across  the  line  of  union 
so  as  not  to  drag  the  surfaces  apart.  Great  care  must 
be  taken  not  to  cut  off  the  twist,  which  makes  it  very 
difficult  to  find  and  extract  the  loop.  It  is  important  to 
remember  the  number  of  sutures  on  a  side,  as  it  is  easy 
to  overlook  one.'  On  more  than  one  occasion  have  I 
known  excellent  surgeons  to  be  censured  for  the  over- 
sight. 

After  the  wires  are  removed,  the  patient  is  again  put 
to  bed  ;  and  the  suture  canals  soon  close.  On  the  four- 
teenth day  she  can  sit  up,  and  in  three  weeks  from  the 
day  of  the  operation  go  about  the  house  if  she  has  done 
well.  Sexual  intercourse  must  be  absolutely  prohibited 
for  two  months,  and  if  the  physician  fears  his  directions 
will  not  be  followed,  it  is  well  to  leave  a  suture  in  the 
cervix ;   tell  the  patient,   without  comment,  that    it  is 

'  See  coil  sutures,  p.  105. 


270    EROSION,   ETC.,    OF  THE   CERVIX  UTERI. 

necessary  to  leave  a  sharp  wire  there  for  a  couple  of 
months,  which  will  do  her  no  harm. 

The  best  time  for  operating  is  a  week  after  the  men- 
strual flow.  While  it  is  easy  to  perform  with  proper 
instruments,  and  union  almost  invariably  follows,  the 
best  results  are  only  obtained  by  careful  attention  to 
detail,  a  thorough  knowledge,  and  some  experience  with 
the  operation. 

Never  try  to  trim  a  hypertrophied  cervix  down  to 
normal  dimensions  in  freshening,  as  the  cervix  will 
undergo  a  kind  of  involution,  as  well  as  the  fundus,  if 
enlarged,  after  the  operation.  Do  not  promise  the 
patient  immediate  relief,  though  some  may  be  experi- 
enced, after  the  operation.  The  best  results  will  be 
seen  six  months  afterward.  The  small  cicatrix  of 
complete  union  between  well-adjusted  surfaces  almost 
always  disappears  in  six  months,  and  will  not  cause 
rigidity  of  the  cervix  in  a  future  labor.  Unless  the 
canal  is  made  abnormally  narrow,  the  operation  does 
not  cause  sterility.  If  three  years  have  elapsed  between 
the  operation  and  the  next  labor,  laceration  of  the  cer- 
vix is  no  more  likely  to  take  place  again  than  at  a  first 
labor  with  the  same  conditions  present. 


ACUTE   METRITIS.  27 1 


CHAPTER    XVIII. 

ACUTE      METRITIS. 

THIS  term  is  used  to  designate  acute  inflammation 
of  the  uterus  from  various  causes.  By  far  the 
most  common  is  inflammation  of  the  uterus  after 
delivery,  which  is  generally  associated  with  septicaemia. 
This  form  will  not  be  considered  here,  as  it  belongs  to 
obstetrics  rather  than  gynaecology. 

Acute  metritis  is  liable  to  become  chronic ;  but  with 
proper  care  and  treatment,  the  acute  symptoms  subside 
within  a  week,  and  the  others  soon  after,  except  in  cases 
of  great  severity. 

The  causes  of  this  affection  are :  chill  during  the 
menses,  with  sudden  suppression  of  the  flow ;  trauma- 
tism from  the  use  of  the  sound,  curette,  tents,  intra- 
uterine pessaries  and  medications  ;  production  of  abor- 
tion and  surgical  operations  on  the  uterus ;  excessive 
venery  and  gonorrhoea. 

The  constitutional  disturbance  will  vary  with  the 
severity  of  the  attack,  and  the  extent  to  which  struc- 
tures adjoining  the  uterus  are  involved.  A  chill  may 
mark  its  commencement,  especially  in  septicaemic  cases  ; 
following  this  there  is  a  rise  in  temperature,  w[ith 
much  local  pain,  sensitiveness,  and  sometimes  throbbing 
in  the  uterine  region,  bearing-down,  not  infrequently 
tenesmus  of  rectum  and  bladder,  and  nausea  and  vomit- 
ing when  the  peritoneum  is  affected.  On  vaginal 
examination,  the  cervix  is  found  congested,  with  heat, 


272  ACUTE   METRITIS. 

dryness,  and  there  is  so  much  tenderness  to  pressure, 
the  uterus  generally  cannot  be  mapped  out  by  a  bi- 
manual examination. 

The  diagnosis  of  acute  inflammation  of  the  uterus  is 
easy  ;  but  whether  it  is  limited  to  that  organ  alone,  it 
is  sometimes  impossible  to  decide.  In  severe  cases 
the  peritoneum  is  generally  involved.  The  pathological 
changes  consist  in  congestion,  enlargement,  and  a  little 
softening  of  the  uterus.  Abscesses  seldom,  if  ever, 
form  within  its  walls,  unless  the  inflammation  is  the 
result  of  septic  infection. 

The  Treatment  consists  in  perfect  quiet  in  bed,  a 
nourishing  fluid  diet,  such  as  milk,  eggs,  soups,  and 
gruels.  In  the  very  beginning  of  the  attack,  a  copious 
hot-water  vaginal  douche  is  excellent  to  control  the 
inflammation.  Suppositories  of  belladonna  may  be 
used  in  the  vagina,  but  no  tampons.  A  hot  bran  or 
moist  hot  hop-bag  on  the  hypogastrium,  will  be  some- 
times of  some  service.  In  cases  of  septic  infection,  the 
hot  douche  should  consist  of  a  1:4000  solution  of 
corrosive  sublimate. 

The  indications  for  the  following  remedies  are  so  well 
known,  it  is  not  considered  necessary  to  repeat  them  in 
detail.  The  reader  is  also  referred  to  the  chapters  on 
Chronic  Metritis  and  Pelvic  Cellulitis  and  Peritonitis. 

THERAPEUTICS. 

Aeon.,  arn.,  ars.,  bell.,  bry.,  canth.,  china,  crocus, 
gels.,  mere,  cor.,  mix  vom.,^  phos.,  puis.,  rhus  tox.,^  veratr. 
vir. 

^  Hartmann  praises  this  remedy  highly  for  metritis  after  labor,  especially  when 
coffea  has  been  drunk  to  excess.  —  The7-apie,  vol.  i.  p.  496. 

^  Dr.  Hoyne  says  rhus  tox.  can  be  relied  on  for  metritis  following  confinement 
with  typhoid  symptoms.  —  Clinic  Therap.,  vol.  i.  p.  131. 


CHRONIC  METRITIS.  273 


CHAPTER    XIX. 

CHRONIC      METRITIS.' 

Synonymes :    Areolar     Hyperplasia,    Parenchymatous    Metritis, 
Sub-Involution,   Congestive   Hypertrophy  of  the  Uterus. 

THE  name  "chronic  metritis  "  is  chosen  as  being  the 
one  in  more  common  use,  though  it  does  not  always 
correspond  to  the  exact  pathological  changes  in  the 
uterus. 

The  disease  consists  essentially  in  an  increased  de- 
velopment of  connective  tissue,  accompanied  by  pas- 
sive congestion,  with  hypertrophy  of  the  uterus.  It  is 
not  necessarily  associated  with,  nor  does  it  follow,  the 
usual  course  of  inflammation.  Sub-involution,^  i.e., 
failure  of  the  uterus  to  undergo  complete  involution 
after  parturition,  may  be  regarded  as  one  of  the  first 
stages  of  chronic  metritis.     It  is  usually  called  a  cause ; 

'  For  a  detailed  description  of  the  pathology  of  this  disease,  and  the  views  oi 
different  authors,  the  reader  is  referred  to  an  exhaustive  article  on  Sub-involution 
and  Chronic  Metritis,  by  Dr.  Mary  Putnam  Jacobi,  in  the  American  Journal  of 
Obstetrics,  p.  802,  1885. 

^  Super-involutio7i,  or  atrophy  of  the  uterus  after  parturition,  the  opposite  con- 
dition to  sub-involution,  is  comparatively  rare,  and  seldom  susceptible  to  treatment, 
unless  the  ovaries  are  in  good  condition.  The  uterus  is  small,  perhaps  an  inch 
and  a  half  deep,  and  the  prominent  symptom  is  amenorrhoea.  Post-partum 
hemorrhage  and  protracted  lactation,  especially  in  scrofulous  subjects,  seem  to  be 
the  most  important  predisposing  causes. 

The  treatment  consists  in  restoring  the  patient  to  her  best  physical  health, 
by  nutritious  food,  exercise,  fresh  air,  etc.  The  galvanic  stem  pessary  has  been 
thought  useful  as  a  local  stimulant.  The  Faradic  current  is  also  well  spoken  of, 
in  preference  to  the  galvanic. 


274.  CHRONIC  METRITIS. 

but,  practically,  it  is  impossible  to  tell  just  when  sub- 
involution merges  into  chronic  metritis,  and  ceases  to  be 
sub-involution.  Chronic  metritis  is  generally  associated 
with  endometritis,  which  frequently  antedates  it ;  and, 
like  endometritis,  may  be  confined  to  either  the  body  or 
cervix  uteri,  the  latter  being  the  more  common  form. 

Although  chronic  metritis  is  seldom  found  in  nulli- 
parae, and  in  the  great  majority  of  cases  begins  with  sub- 
involution, the  latter  is  not  the  only  form  of  the  disease, 
A  uterus  may  undergo  complete  involution,  and  in 
consequence  of  some  predisposing  cause,  as  a  scrofulous 
diathesis,  debility,  or  too  frequent  parturition,  chronic 
metritis  develop  afterward  from  one  of  the  following 
exciting  causes  :  chronic  congestion  of  the  uterus  from 
obstruction  to  the  portal  circulation,  uterine  displace- 
ment, neoplasms,  the  practice  of  incomplete  sexual 
intercourse,  intentional  or  otherwise  ;  also,  the  exciting 
causes  of  sub-involution,  laceration  of  the  cervix,  puer- 
peral pelvic  inflammation,  getting  up  too  soon  after 
delivery,  or  coition  before  the  sexual  organs  have 
undergone  complete  involution. 

The  Symptoms  vary  in  different  cases,  and  can  hardly 
be  separated  from  those  of  the  complications  which  are 
usually  present,  such  as  laceration  of  the  cervix,  endo- 
metritis, etc. 

In  most  cases  there  are  backache  and  bearing-down 
sensations  in  the  pelvis,  worse  on  walking;  vesical 
tenesmus,  and  painful  or  difficult  defecation  from  press- 
ure on  the  bladder  or  rectum  ;  dyspareunia ;  leucorrhoea  ; 
dysmenorrhoea ;  headache ;  and  not  infrequently,  dys- 
pepsia. 

On  bi-manual  examination,  the  uterus  is  found  en- 
larged, and  often,  though  not  always,  sensitive.  It  sags 
down  in  the  pelvis,  so  that  the  cervix  often  rests  on  the 
pelvic  floor,  while  the  fundus  tips  in  some  abnormal 


PROGNOSIS  AND    TREATMENT.  2/5 

direction.  The  sound  shows  an  abnormal  depth  of  the 
cavity.  Where  the  disease  is  limited  to  the  cervix, 
however,  both  the  cavity  and  fundus  are  of  the  normal 
depth. 

The  diagnosis  of  sub-involution  is  made  by  the  men- 
orrhagia  following  parturition,  and  the  increased  size  and 
depth  of  the  uterus. 

The  Prognosis  in  hyperplasia,  affecting  the  body  of 
the  uterus,  is  unfavorable  as  regards  perfect  and  perma- 
nent cure,  but  the  patient  can  be  relieved  of  her  symp- 
toms to  such  an  extent  that  she  will  suffer  little,  if  any, 
except  as  the  result  of  some  imprudence,  when  they 
will  return.  In  hyperplasia  of  the  cervix,  the  prognosis 
is  favorable,  as  the  complications  are  fewer  and  less 
serious. 

The  Treatment  of  this  disease  must  be  persistent  and 
continuous  for  months  if  necessary.  No  permanent 
benefit  will  be  derived  from  occasional  prescriptions  or 
applications.  As  it  is  so  often  associated  with  the 
puerperal  state,  it  may  not  be  out  of  place  to  call 
attention  to  its  management.  The  patient  should  have 
plenty  of  pure  fresh  air,  and  be  fed  freely  as  she  can  bear 
it,  instead  of  dieted  on  thin  gruel,  toast-tea,  and  other 
non-nutritious  delicacies  so  popular  in  the  lying-in  room. 
Sleep  is  essential.  It  is  a  good  plan  to  take  the  child 
into  another  room,  so  that  the  mother  can  rest  undis- 
turbed. From  the  beginning,  the  child  can  nurse  at 
midnight,  and  not  again  till  four  in  the  morning.  This 
interval  can  be  soon  lengthened  gradually,  and  the 
mother  have  six  or  eight  hours  sleep  without  the  baby's 
remonstrance. 

It  is  of  paramount  importance  for  the  physician  to 
be  absolutely  sure  of  firm  and  permanent  contractions 
of  the  uterus  before  leaving  the  patient.  A  binder 
properly  applied,  so  as  to  support  the  relaxed  abdom- 


2/6  CHRONIC  METRITIS. 

inal  walls  for  the  first  three  days  after  delivery,  is  a 
comfort  to  the  mother ;  but  a  very  tight  bandage,  par- 
ticularly if  there  is  a  pad  under  it,  is  very  injurious. 
Besides  a  careful  watch  for  any  inflammatory  symptoms, 
the  obstetrician  should  not  allow  the  patient  to  sit  up 
before  the  fundus  uteri  has  receded  to  the  pelvic  brim,' 
and  should  emphatically  forbid  any  sexual  intercourse 
during  the  three  months  following  delivery. 

It  is  of  great  importance  to  ascertain  and  remove  all 
causes  of  the  disease,  or  complications  which  tend  to 
keep  it  up,  such  as  endometritis,  vaginitis,  laceration  of 
the  cervix,  or  displacement  of  the  uterus.  Neglect  to 
do  this  is  the  reason  why  so  many  women  fail  to  receive 
any  benefit  from  treatment. 

Not  infrequently  there  is  a  fungoid  or  polypoid 
degeneration  of  the  endometrium,  characterized  by 
profuse  menorrhagia ;  unless  internal  remedies  relieve, 
it  will  be  necessary  to  use  the  blunt  wire  curette  to 
remove  the  minute  growths. 

Any  displacement  must  be  corrected,  so  that  the 
circulation  will  be  free  and  unimpeded.  The  clothing 
ought  to  be  loose  about  the  waist,  and  the  skirts  sus- 
pended from  the  shoulders.  If  an  abdominal  bandage 
can  be  smoothly  fitted  so  as  to  take  off  the  weight  of 
the  intestines  from  the  pelvic  organs,  it  will  add  much 
to  the  comfort  of  the  patient. 

Perfect  sexual  rest  is  necessary.  The  patient  should 
keep  her  bed  during  the  menstrual  periods,  and  take  a 
limited  amount  of  exercise  in  the  open  air  every  day. 
Housework,  going  up  and  down  stairs,  using  a  sewing- 
machine,  and  long  walks,  must  be  prohibited.  A  plain 
nutritious  diet   is   advisable  to   maintain   the   patient's 

'  This  is  readily  ascertained  by  the  hand  on  the  hypogastrium.  It  varies  from 
eight  to  fourteen  days  after  delivery.  See  Rest  after  Delivery,  by  Dr.  Garrigues, 
American  Journal  of  Obstetrics,  October,  1880,  p.  861. 


LOCAL    TREATMENT.  277 

health  and  strength.  The  mineral  waters  of  Kreuz- 
nach,  Germany,  have  a  considerable  reputation  in  the 
treatment  of  this  disease. 

Local  depletion  by  puncture  or  scarification  of  the 
cervix,  so  as-  to  allow  about  a  tablespoonful  of  blood  to 
escape,  will  temporarily  relieve  the  patient ;  but  it  is 
difficult  to  see  how  any  permanent  good  will  result. 
Too  much  importance  cannot  be  attached  to  the 
systematic  use  of  copious  hot-water  vaginal  douches, 
which  may  be  combined  with  hot  sitz-baths.' 

Great  benefit^  is  sometimes  derived  from  a  mild 
galvanic  current  applied  every  second  or  third  day  for 
three,  or  even  four,  months  if  necessary  ;  the  negative 
pole  being  placed  on  or  within  the  uterus,  and  the  posi- 
tive over  the  hypogastrium.  I  have  so  far  used  a 
current  of  eight  to  twelve  milliamperes  for  this  pur- 
pose. 

Many  physicians  prefer  the  compound  tincture  of 
iodine  for  an  application  to  the  cervical  canal  or  uterine 
cavity,  according  to  the  site  of  the  hyperplasia.  Other 
good  authorities  speak  highly  of  the  use  of  iodized 
phenol  twice  a  week.  When  the  latter  is  used  for  the 
first  time,  it  is  well  to  tell  the  patient  that  a  bloody 
discharge  will  probably  follow,  and  that  it  is  no  cause  for 
alarm.  A  mixture  of  glycerine  and  iodine,  applied  on 
tampons,  has  often  a  beneficial  effect.  Powerful  caus- 
tics, such  as  chemically  pure  nitric  acid,  the  acid  nitrate 
of  mercury,  the  solid  nitrate  of  silver,  etc.,  are  apt  to 
do  far  more  harm  than  good,  and  should  never  be  em- 
ployed. In  marked  cervical  hyperplasia,  amputation  by 
removal  of  wedge-shaped  pieces  from  the  anterior  and 

'  See  chapter  on  Minor  Surgical  Gynaecology,  p.  9. 

^  Dr.  Munde  has  an  excellent  article  on  Electricity  in  Gynaecology,  in  the 
American  Journal  of  Obstetrics,  p.  1233,  1S85. 

^  Dr.  Rockwell  has  written  a  detailed  account  of  Electricity  in  GynEecology,  in 
the  American  Sy^em  of  Gynaecology,  vol.  i.  p.  383. 


2/8  CHRONIC  METRITIS. 

posterior  lips  by  Marckwald's  method/  has  often  a 
decided  alterative  action,  and  is  followed  by  diminution 
in  the  size  of  the  uterus.  When  chronic  metritis  is 
associated  with  laceration  of  the  cervix,  an  operation  on 
the  latter  will  materially  reduce  the  size  of  the  uterus 
by  its  alterative  effect/  Any  successful  treatment  must 
be  persistent  and  long  continued.  Too  much  must  not 
be  expected  from  the  remedy  selected  without  allowing 
sufficient  time  for  it  to  act.  Some  cases  are  very  diffi- 
cult to  relieve,  while  in  others  the  favorable  effect  of 
the  remedy  is  very  soon  apparent. 

THERAPEUTICS. 

Arsenicum.  The  iodide  is  preferred  by  some.  It  is 
adapted  to  both  acute  and  chronic  cases ;  burbling,  throbbing, 
lancinating  pains  in  the  uterus  ;  similar  pains  extending  from  the 
abdomen,  or  ovaries,  more  especially  the  right,  into  the  uterus, 
vagina,  or  thighs,  which  feel  numb  or  lame,  worse  from  motion 
or  sitting  bent  over;  leucorrhoea  profuse,  thick,  yellowish 
(Hydrastis,  kali  hi.),  corrosive  {^Alumina,  kali  carb.,  kreosote, 
mere,  puis.)  ;  great  restlessness,  prostration,  thirst,  but  worse 
from  drinking  cold  water;  aggravation  of  symptoms  about 
midnight,  if  the  symptoms  are  of  a  typhoid  type ;  threatened 
putrefaction  or  gangrene  (Secale  cor.,  lach.). 

Aurum.  Chronic  cases  of  long  standing.  The  uterus  sags 
low  down  in  the  pelvis,  and  is  indurated ;  suicidal  melancholia, 
scrofulous,  syphilitic,  or  mercuriahzed  subjects.  Dr.  E.  C. 
Priced  finds  aur.  mur.  nat.  2x4  (chloride  of  gold),  next  to  ars. 
iod.,  the  best  remedy  for  cervical  enlargement. 

'  Arch.  f.  Gyn.,  Bd.  viii.  S.  48. 

^  Compare  chapter  on  Laceration  of  the  Cervix. 

3  He  also  speaks  well  of  ferr.  iod.  for  the  chronic  form,  with  tenesmus  of  the 
rectum  and  bladder,  with  bearing-down.  —  Am.  Horn.  Observer,  p.  114,  March,  1881 . 

•♦  Dr.  Tritschler  very  warmly  praises  the  chloride  of  gold  3X.  for  indurations  or 
hypertrophy  of  the  uterus,  and  quotes  a  number  of  interesting  cases,  associated  with 
extreme  displacement  of  the  uterus,  generally  posterior,  also  with  sterility,  cured 
by  this  remedy.  He  states  the  effect  cannot  be  seen  before  four  weeks,  and  that 
many  women  notice  a  remarkable  increase  in  the  appetite  during  the  use  of  gold. 


THERAPEUTICS  OF  CHRONIC  METRITIS.    279 

I  Belladonna.'  Acute  cases.  Arterial  congestion  of  the 
uterus  (Sabina,  lil.  tig.)  ;  on  vaginal  examination,  there  is 
marked  pulsation  in  tlie  pelvic  organs,  a  sensation  of  heaf,  and 
great  sensitiveness ;  there  is  much  bearing-down,  backache, 
throbbing  headache,  face  flushed,  and  even  delirium  ;  the  lochia 
feels  hot  to  the  patient  \  menorrhagia  with  profuse,  hot,  red  flow ; 
menses  too  early  (Amm.  carb.,  calc.  carb.,  nux  vom.). 

Calc.  carb.  or  iodide.  Strumous  diathesis,  chronic  cases, 
sub-involution ;  menses  too  eai'ly,  too  long,  and  too  profuse 
(Aloe,  ambr.,  amm.  carb.,  bell.,  brom.,  cyclamen,  coccus  cac, 
nux  vo?n.)  ;  milky  leucorrhoea  (Coni.,  lye,  puis.,  sepia,  sulph. 
ac.)  ;  profuse  perspiration  from  the  least  exertion,  chiefly  about 
the  head ;  feet  feel  cold  and  damp ;  acidity  of  the  stomach. 
The  patient  feels  worse  during  and  after  coition. 

Iodine  is  mentioned  by  Hempel  ^  on  clinical  evidence ; 
induration  and  swelhng  of  uterus  and  ovaries  (Coni.)  ;  metror- 
rhagia, worse  after  every  stool ;  acrid,  corrosive  leucorrhcea, 
worse  at  time  of  menses ;  the  breasts  dwindle  away,  and  be- 
come flabby;  local  or  general  emaciation.  In  a  case  where 
there  was  intense  pain  in  the  region  of  the  uterus,  the  abdomen 
very  sensitive  with  continual  urging  to  urinate,  heat  and  dryness 
of  the  vagina,  and  suppression  of  the  lochia,  iodine  removed 
the  pain  at  once,  restored  the  lochial  discharge,  and  freed  the 
patient  from  danger.  Hering  states  that  this  drug  should  not 
be  given  during  the  lying-in  period,  except  in  high  potencies. 

Lilium  tigrinum.  Recommended  by  Dr.  Hughes,  where 
there  is  arterial  congestion  of  the  uterus  (Sabina,  bell.)  ;  much 
general  nervous  irritability ;  local  pain  and  sensitiveness,  with 
tendency  to  diarrhoea ;  there  is  also  continuous  pressure  on  the 
bladder ;  constant  desire  to  urinate  during  the  day,  with  scanty 
discharge,  followed  by  burning  and  smarting  in  the  urethra; 
marked  "  bearing- down  "  sensation  in  the  pelvis ;  sharp  pains 
in  the  ovarian  region. 

(Compare  Hahn.  Monthly,  1S77 ;  also  Horn.  Recorder,  p.  102,  May  15,  1877, 
quoted  from  the  Allgemeine  Hem.  Zeitung,  Bd.  94,  Nos.  17,  18,  19.) 

^  This  remedy  is  very  highly  commended  for  acute  metritis  by  Dr.  Matheson. 
Compare  his  four  lectures  on  the  Diseases  of  Women,  metritis. 

*  Comprehensive  System  of  Mat.  Med.  and  Therap.,  ist  ed.  p.  548. 


28o  CHRONIC  METRITIS. 

Pulsatilla.  Sensation  of  weight  in  the  abdomen  and  lum- 
bar region,  especially  during  menses ;  menses  suppressed  from 
wetting  the  feet,  or  delayed  ;  leucorrhoea  thick,  like  cream  or 
milk,  painless,  acrid,  thin,  burning,  with  swollen  vulva  (Ars.)  ; 
patient  suffers  from  dyspepsia,  has  a  tendency  to  diarrhoea,  and 
feels  much  better  in  the  open  air. 

I  Sabina.  Arterial  congestion  of  the  uterus  (Bell.,  hi.  tig.)  ; 
hemorrhage,  rectal  or  vesical  irritation,  or  both  at  the  same  time. 
Hemorrhage  from  the  uterus,  in  paroxys7ns,  worse  from  motioti ; 
blood  dark  {^Crocus,  cyclamen,  kali  nit?)  and  clotted  (^Amm.  carb., 
cycla.,  ign.,  plat.),  from  loss  of  tone  in  the  uterus  (Caul.),  after 
abortion  or  parturition,  with  pain  in  back  to  pubis  ^  menses  too 
profuse,  too  early,  atid  last  too  long  (yBelL,  calc.  carb.,  kali  carb., 
nux  vo7n.).  Metritis  after  parturition,  or  abortion  at  about  the 
third  month ;  sexual  desire  almost  insatiable.  It  is  especially 
suitable  to  what  might  be  termed  sub-acute  metritis. 

II  Secale  is  the  great  remedy  for  sub-involution,  both  for 
the  ordinary  cases  characterized  by  an  atonic  condition  of  the 
uterus,  and  the  severe  ones  where  gangrene  threatens  {Ars., 
lach.,  rhus),  with  a  general  adynamic  condition  of  the  system  ; 
uterine  hemorrhage,  worse  from  the  least  motion  (Erig.,  sabina)  ; 
discharge  black,  fluid,  and  very  fetid.  After  an  abortion,  the 
uterus  does  not  contract ;  thin,  black,  offensive  discharge  ;  sup- 
pressed lochia  followed  by  metritis  {Aeon.,  bell.)  ;  extreme 
debility,  prostration,  and  restlessness  (Ars.).  The  lower  dilu- 
tions of  a  fresh  preparation  are  more  often  used  for  sub- 
involution. 

II  Sepia.  Venous  congestion  of  the  uterus  and  pelvic 
tissues  (Murex  purpurea)  ;  prolapsus  uteri ;  pain  in  the  uterus, 
and  such  severe  bearing-down,  the  patient  feels  as  if  she  must 
cross  the  limbs  to  prevent  protrusion  of  the  parts  ;  leucorrhoea 
yellow,  milky  (Calc.  carb.,  coni.,  lye,  puis.,  sulph.  ac),  excori- 
ating {Alum.,  ars.,  kreos.,  mere),  worse  before  the  menses.  Dr. 
Leadam  states  that  sepia  is  suitable  to  the  chronic,  indurated 
condition  of  the  uterus,  its  cervix  and  os,  whether  benign  or 
malignant.  The  general  symptoms  of  the  patient  indicating 
this  remedy  are  to  be  borne  in  mind. 


THERAPEUTICS  OF  CHRONIC  METRITIS.    28 r 

I  Sulphur.  An  excellent  authority  recommends  the  use  of 
this  remedy  intercurrently  in  different  dilutions,  during  the  treat- 
ment of  chronic  cases,  no  matter  what  other  medicines  are 
given.  Should  the  well-known  general  symptoms  of  sulphur 
be  present  in  addition  to  the  local  ones,  this  would  be  all  the 
more  important ;  menses  too  late,  too  profuse,  but  of  too  short 
duration ;  blood  thick,  dark,  sour-smelling,  and  excoriating ; 
profuse,  yellowish,  corrosive  leucorrhoea  ;  burning  in  the  vagina, 
and  itching  of  the  genitals. 

Ustilago  maidis.'  Metritis  and  ovarian  irritation,  when 
there  is  acute  pain,  especially  in  the  left  ovary,  with  swelling ; 
menses  too  soon  and  too  profuse ;  hemorrhage  with  clots, 
bearing-down,  as  if  every  thing  would  come  through.  A  fresh 
preparation  is  important. 

The  following  remedies  may  be  consulted  for  further 
information  :  — 

Sub-involution.  —  China,  calc.  phos.,  cauloph.,  crocus, 
helonias,  ipecac,  mere,  iod.,  nat.  mur.,^  rhus  tox.,  tril- 
lium. 

Chronic  metritis.  —  Baryta  carb.,  carbo  veg.  or  an., 
cocculus,  collinsonia,  coloc,  coniuin,  ferrum,  gels., 
hepar  sulph.,  hyosc,  ignatia,  iris,  kali  iod.,  kali  bi., 
kreosote,  lach.,  lye,  magnesia  mur.,^  mere,  iod.,  murex 
purpurea,-^  nux  vom.,  phos.,  phytolacca,  plat.,  puis., 
sodse  chlor.,5  verat.  alb.'' 

'  Raue,  Record  of  Horn.  Lit,  1873,  P-  S^- 

^  Dr.  H.  H.  Read  writes  me  that  "  Natr.  mur.  did  wonders  in  a  case  of  sub- 
involution following  puerperal  inflammation,  probably  traumatic."  I  prescribed  it 
from  the  symptom,  "  Dreams  of  robbers  in  the  house." 

3  Dr.  Hughes  speaks  favorably  of  it  in  venous  congestion  of  the  uterus  where 
the  liver  is  at  fault.     Dr.  Jahr  also  used  it  with  success. 

'•■  If  the  symptoms  are  similar  to  those  of  sepia  and  the  menses  are  free,  while 
with  sepia  the  flow  is  rather  scanty. 

5  Dr.  Cooper  :  Brit.  Jour,  of  Horn.,  No.  cxxvi. 

''  Mrs. .     Been  sick  three  months  before  coming  under  my  care ;    great 

weakness  ;  face  pale ;  eyes  sunken,  with  dull  expression  ;  extremities  cool.  She 
complained  of  violent  uterine  pains,  with  a  feeling  of  heaviness,  which  was  attended 


282  CHRONIC  METRITIS. 

by  stitching  pains,  particularly  on  the  posterior  wall  of  the  uterus.  She  could  not 
rise  because  of  the  pain  ;  entire  loss  of  appetite ;  slimy  diarrhcEic  stools ;  con- 
stantly cold,  especially  the  extremities.  Physical  examination  showed  the  volume 
of  the  uterus  increased,  hard  and  sensitive  to  the  touch,  congestion  of  the  neck  of 
the  uterus,  and  the  least  touch  of  it  made  her  scream.  Bell.,  nu.'c  vom.,  and  bry. 
did  little.  Veratr.  alb.  6  cured  her  in  two  weeks.  —  Dr.  Sentin,  in  Hoyne's 
Clinical  Therapeutics,  vol.  i.  p.  322. 


BENIGN  GROWTHS   OF   THE    UTERUS.        283 


CHAPTER    XX. 

BENIGN     GROWTHS     OF     THE     UTERUS. 

Fibroid  Tumors  (Myoma,  Fibre-Myoma),  Fibro-Cystic  Tumors, 
Fibrous  Polypi,  Fungoid  Endometritis,  Glandular  Polypi, 
Cellular  Polypi  (the  last  three  are  varieties  of  Adenoma). 

THESE  growths  are  considered  in  one  chapter 
because  their  subjective  symptoms  are  similar, 
differing  only  in  degree,  according  to  the  size  and 
situation  of  the  tumor,  and  the  same  general  principles 
of  treatment  apply  to  all. 

The  fibroid  tumor,  also  known  as  a  myoma  or  fibro- 
mybma,  may  be  single  or  multiple,  the  size  of  a  pea,  or 
large  enough  to  fully  distend  the  abdominal  cavity,  and 
usually  has  a  distinct  capsule,  especially  if  it  be  of  long 
duration.  It  is  most  common  near  the  fundus  uteri,  on 
the  posterior  wall,  and  is  seldom  found  in  the  cervix. 
The  surface  is  smooth,  as  a  rule,  rarely  a  little  irregular. 
The  stony  hardness  of  a  circumscribed  mass  within  or  in 
connection  with  the  uterus  is  characteristic  of  a  uterine 
fibroid.  Microscopically,  it  consists  of  hypertrophied 
connective  and  muscular  tissue,  and  the  degree  of  hard- 
ness depends  largely  on  the  density  of  the  fibrous 
elements.  Though  generally  very  hard,  fibroids  are 
sometimes  found  which  have  a  moderate  amount  of 
elasticity,  and  are  therefore  called  soft  or  osdematous 
fibroids.  In  the  latter,  the  connective  tissue  fibres  are 
not  as  compact ;  are  separated  by  a  jelly-like  substance. 


284        BENIGN  GROWTHS  OF  THE   UTERUS. 

and  the  tumor  is  composed  almost  entirely  of  muscular 
elements.  The  soft  fibroids  grow  more  rapidly  than  the 
hard,  and  occur  in  younger  women  (Virchow).  They 
are  often  observed  to  vary  in  size,  being  larger  just 
before  the  menstrual  periods. 

Endometritis  is  generally  induced  by  the  presence  of 
a  fibroid  tumor,  especially  if  it  be  of  the  sub-mucous 
variety.  In  examining  numerous  preparations,  Dr. 
Wyder '  found  glandular  endometritis  accompanying 
interstitial  and  sub-serous  fibroids.  This  glandular 
endometritis  was  more  marked  in  proportion  to  the 
thickness  of  the  muscular  wall  between  the  tumor  and 
the  uterine  cavity.  The  thinner  the  wall,  as  in  sub- 
mucous fibroids,  the  greater  the  growth  of  connective 
tissue  (interstitial  endometritis).  The  glandular  endo- 
metritis shows  no  predisposition  to  malignant  degener- 
ation of  the  mucous  membrane,  and  in  the  pure  form 
Dr.  Wyder  believes  it  does  not  cause  bleeding.  Bleed- 
ing is  in  consequence  of  the  development  of  connective 
tissue  and  blood-vessels  (endometritis  fungosa)  ;  or  if 
one  portion  grows  very  much  faster  than  another,  it  may 
compress  the  veins,  and  cause  the  blood  to  stagnate 
or  back  up  in  them,  and  thus  produce  hemorrhage. 

Apart  from  the  inflammatory  disorders  of  the  pelvic 
tissues,  and  anomalies  of  menstruation*,  this  affection  is 
one  of  the  more  common,  if  not  the  most  frequent,  of 
the  diseases  peculiar  to  women.  Fibrous  tumors  are 
also  found  in  various  parts  of  the  body,  less  often  in  the 
male  than  female.  They  are  almost  unknown  before  or 
at  puberty,  but  from  this  time  gradually  increase  in 
frequency,  and  in  the  majority  of  cases  develop  between 
thirty  and  forty  years  of  age.  Their  growth  is  very 
slow,  usually  ceasing  after  the   climacteric,  and  life  is 

I  Wyder :  Die  Mucosa  Uteri  bei  Myotnen.  Archiv.  fiir  Gynakologie,  Bd.  xxix. 
Hft.  i. 


FIBROID    TUMORS  OF  THE   UTERUS.         285 

endangered  only  in  consequence  of  mechanical  pressure 
or  profuse  menorrhagia.  When  small,  and  situated 
beneath  the  peritoneal  investment  of  the  uterus,  there 
are  seldom  any  symptoms,  and  the  patient  may  never 
be  aware  of  their  presence. 

The  negro  race  is  peculiarly  liable  to  their  develop- 
ment, much  more  so  than  the  white.  It  seems  to  be 
true,  also,  that  of  the  large  pelvic  tumors,  fibroids  pre- 
dominate in  the  African,  and  ovarian  in  the  white  races. 

The  relation  of  the  etiology  of  fibroid  tumors  to 
single,  fruitful,  and  sterile  women,  has  been  carefully 
studied,  and  nearly  all  observers  find  that  they  are 
much  more  common  in  married  than  single  women.' 
Gusserow^  collected  the  records  of  nine  hundred  and 
fifty-nine  women  affected  with  these  growths.  Six 
hundred  and  seventy-two  were  married,  and  two  hundred 
and  eighty-seven  unmarried.  Of  the  married  ones  four 
hundred  and  sixty-four  had  borne  children,  and  the 
remainder  were  sterile.  He  believed,  from  the  recorded 
experience  of  physicians,  that  the  sterility  was  a  result 
rather  than  a  cause  of  the  development  of  the  tumor. 
Both  Schroeder^  and  WinckeH  agree  with  him  in  this 
opinion. 

In  five  hundred  and  fifty-five  women  having  uterine 
fibroids,  Winckel  found  one  hundred  and  forty  (24.2 
per  cent)  were  childless  and  single ;  four  hundred  and 
fifteen  were  married  (75.8  per  cent),  and  of  these  one 
hundred  and  thirty-four  (24.3  per  cent)  were  sterile. 
According  to  the  population  of  Saxony,  the  proportion 
of  middle-aged  married  women  to  single  women  was  as 
9  to  7.3,  and  the  prevalence  of   fibroid  tumors  among 

^  The  statistics  of  Routh  show  that  this  is  true  of  women  in  England. — 
Schmidts  Jahrbiicher^  p.  236,  vol.  129,  1866. 

2  Die  Neubildungen  des  Uterus,  chap.  iii. ;  Deutsche  Chirurgie,  1885. 

3  Krankheiten  der  weibl.  Geschlectsorgane,  s.  210,  1881. 

^  Winckel :  Diseases  of  Women,  American  ed.,  p.  409,  1887. 


286        BENIGN  GROWTHS  OF   THE   UTERUS. 

the  unmarried  to  that  among  the  married  as  3  to  9 ;  in 
other  words,  tumors  of  this  nature  occur  nearly  twice 
as  often  among  the  married  as  in  the  unmarried. 

Gusserow  and  Schroeder  believe  that  sexual  gratifi- 
cation rather  favors  the  development  of  uterine  fibroids. 

While  these  opinions  concerning  the  etiology  of  uter- 
ine fibroids  have  obtained  general  acceptance,  there  are 
some  physicians  who  differ  from  them.  In  a  very  care- 
fully written  essay  based  on  great  experience  and  the 
personal  study  of  over  two  hundred  cases.  Dr.  Emmet ' 
thinks  those  women  who  have  not  had  children,  i.e.,  the 
unmarried  and  sterile  classed  together,  are  more  liable 
to  fibroids  than  those  who  have  borne  children.  Ac- 
cording to  him,  the  fruitful  are  more  liable  than  either 
the  unmarried  or  sterile  considered  separately,  while  the 
last  two  classes  are  nearly  equal  in  liability  before  thirty 
years  of  age.  He  believes  their  development  is  held  in 
check  by  marriage,  even  though  conception  does  not 
take  place ;  also,  that  "  between  the  ages  of  thirty  and 
forty  the  unmarried  woman  is  fully  twice  as  subject 
to  large  fibroid  tumors  as  the  sterile  or  fruitful,"  and 
that  sterile  women  are  more  subject  to  small  fibroid 
growths  than  either  unmarried  or  fruitful  women  ;  he  is 
also  of  the  opinion  that  sexual  gratification  diminishes 
the  liability  to  fibroid  tumors. 

The  complications  and  symptoms  are  those  arising 
from  pressure  of  the  tumor  on  the  neighboring  struc- 
tures, and  increased  determination  of  blood  to  the 
uterus.  They  vary  somewhat  according  to  the  situation 
of  the  tumors,  which,  for  convenience  of  description, 
are  divided  into, — 

Interstitial  fibroids,  when  situated  in  the  parenchyma 
of  the  uterus  (65/0).^ 

'  Principles  and  Practice  of  Gynaecology,  p.  548,  1884. 
"  Winckel,  Diseases  of  Women,  Am.  ed.,  p.  408,  1877. 


SYMPTOMS  OF  FIBROID    TUMORS.  287 

Sub-peritoneal  fibroids,  when  situated  beneath  the 
peritoneal  covering  of  the  uterus  (25/0).' 

Sub-mucous  fibroids,  when  situated  beneath  the 
endometrium,  and  projecting  into  the  uterine  cavity 
(lofo)/ 

If  a  sub-mucous  fibroid  projects  far  enough  to  have 
a  distinct  pedicle,  it  is  then  termed  a  fibroid  polypus. 
It  is  probable  that  many  fibroids  begin  as  interstitial 
tumors  near  the  endometrium  or  peritoneal  surfaces. 
As  their  size  increases,  they  tend  to  grow  in  the  direc- 
tion of  the  least  resistance,  and  with  the  help  of  mus- 
cular contraction  of  the  uterine  parenchyma,  become 
eventually  sub-serous  or  sub-mucous  fibroids. 

The  Symptoms  are  most  pronounced,  and  constantly 
produced,  by  sub-mucous  fibroids  and  fibrous  polypi ; 
less  frequently  by  interstitial ;  and  are  often  few  or 
entirely  absent  in  the  sub-peritoneal  variety.  Profuse 
menorrhagia  or  metrorrhagia  is  one  of  the  most  con- 
stant symptoms ;  and  in  the  interval  between  the  low- 
ing, there  is  a  watery  or  leucorrhoeal  discharge  from 
the  uterus.  The  flowing  first  appears  as  an  increase  of 
the  monthly  flow,  and  gradually  becomes  excessive  with 
later  periods,  instead  of  a  sudden  and  profuse  hemor- 
rhage as  in  carcinoma.  There  is  also  more  or  less  weight 
and  bearing-down  in  the  pelvis,  pelvic  pain,  irritability 
of  rectum  and  bladder,  and  pain  along  the  course  of  the 
crural  nerves,  all  of  which  result  from  pressure.  Dys- 
menorrhoea  is  sometimes  present.  Though  these  symp- 
toms may  be  marked,  the  diagnosis  of  uterine  fibroids 
cannot  be  made  without- — 

The  Physical  Examination.  —  Large  fibroid  tumors, 
extending  into  the  abdominal  cavity  above  the  brim  of 
the  pelvis,  are  readily  diagnosed  in  the  great  majority 
of  cases  by  abdominal  palpation.     They  are  more  often 

■  Winckel,  Diseases  of  Women,  Am.  ed.,  p.  408,  1877. 


288        BENIGN  GROWTHS  OF  THE    UTERUS. 

sub-peritoneal  than  sub-mucous,  uniformly  hard,  and 
may  be  situated  at  the  centre  or  on  one  side  of  the 
abdomen.  The  surface  is  generally  irregular,  from 
the  presence  of  one  or  more  smaller  fibroids,  all  of 
which  form  a  single  mass,  held  together  by  a  frame- 
work of  connective  tissue ;  or,  less  frequently,  the 
surface  is  smooth  when  a  single  tumor  is  present. 
Like  all  fibroid  tumors,  they  develop  slowly. 

Sometimes  the  fibroid  may  project  far  enough  from 
the  uterus  to  have  a  short  thick  pedicle ;  but  the  uterus 
will  always  move  with  the  tumor,  as  shown  by  the 
introduction  of  the  sound  within  the  uterine  cavity, 
and  motion  given  to  the  tumor  will  be  communicated 
to  the  sound. 

While  the  presence  of  a  large  fibroid  can  almost  always 
be  ascertained  by  the  means  just  indicated,  it  is  well 
to  follow  the  method  of  examination  given  below  for  a 
small  fibroid,  which  is  sometimes  difficult  to  detect  with 
absolute  certainty. 

The  best  time  to  make  an  examination  is  very  soon 
after  the  monthly  has  ceased,  though  this  is  by  no 
means  necessary  or  advisable  if  the  flowing  is  almost 
continuous.  The  tissues  are  then  more  relaxed,  the 
cervical  canal  open,  and  the  cervix  soft,  allowing  a  cer- 
tain amount  of  dilatation  with  the  finger  as  the  uterus 
is  crowded  down  upon  it  by  the  external  hand.  The 
tumor,  therefore,  can  be  felt  better  at  this  time. 

In  all  cases  it  is  a  good  rule  to  have  the  patient  in  a 
position  in  which  she  can  be  examined  to  the  best 
advantage.  Although  a  fair  idea  of  her  condition  may 
be  obtained  while  she  lies  on  her  back  on  a  firm  mat- 
tress or  sofa,  it  is  much  better  to  place  her  on  a  table 
or  gynaecological  chair.  All  constricting  bands  about 
the  waist,  and  corsets,  must  "be  removed,  and  the  thighs 
flexed  on  the  abdomen  to  relax  the  muscles  as  much  as 


DIAGNOSIS  OF  FIBROID   TUMORS.  289 

possible.  In  all  doubtful  cases,  ether  anaesthesia  will 
be  of  great  assistance  in  making  a  thorough  examina- 
tion. A  hot  (110°)  mercurial  douche  (i  14000)  before 
and  after  the  latter  is  also  advisable. 

It  is  hardly  necessary  to  state  that  the  bi-mahual 
method  of  examining  must  be  an  invariable  rule,  and 
the  cultivation  of  a  gentle  touch  without  prying  and 
prodding  about  in  the  pelvis  is  very  desirable. 

The  cervix  is  quite  commonly  found  displaced.  If 
the  tumor  be  large,  extending  above  the  pelvic  brim, 
the  cervix  is  often  drawn  up,  and  sometimes  out  of 
reach.  When  the  tumor  is  in  the  anterior  or  posterior 
wall  of  the  uterus,  that  organ  is  displaced  in  the  corre- 
sponding direction,  particularly  if  it  be  of  the  sub- 
peritoneal variety.  This  is  readily  ascertained  by  care- 
ful bi-manual  palpation,  and  the  relation  of  the  growth 
to  the  uterus.  In  exceptional  cases  when  the  fibroid 
is  sub-mucous,  less  often  if  it  lies  in  the  posterior 
uterine  wall,  the  cervix  is  low  down  in  the  pelvis.  The 
stony  hardness  of  the  tumor,  which  is  seldom  sensitive 
to  pressure,  its  slow  development,  associated  as  a  rule 
with  menorrhagia  in  a  woman  about  forty  years  old,  are 
very  characteristic  symptoms  of  a  uterine  fibroid. 

It  is  not  always  as  easy  to  distinguish  the  class  of 
fibroids  to  which  it  belongs.  The  sub-peritoneal  may 
be  felt  like  a  hard  lump  attached  to  the  uterus,  having 
a  sort  of  ring  or  constriction  at  that  place ;  while  the 
intra-mural  (interstitial)  feels  more  like  a  hard  bunch 
bulging  out  from  that  organ,  with  a  perfectly  smooth 
sloping  surface,  and  no  constriction  around  the  base  of 
the  tumor.  A  rectal  examination  will  often  be  of  great 
service  when  the  tumor  is  in  the  posterior  part  of  the 
pelvic  cavity.  If  the  fibroid  be  sub-mucous,  the  fundus 
is  more  symmetrically  enlarged  than  in  either  of  the 
preceding  varieties.      Sometim.es  the  tumor  is  readily 


290        BENIGN  GROWTHS   OF   THE    UTERUS. 

felt  presenting  at  the  external  os  ;  or  by  crowding  the 
finger  firmly  up  in  the  cervical  canal,  and  pressing 
down  on  the  uterus  externally,  it  is  distinguished  near 
the  internal  os. 

It  is  always  desirable  to  ascertain,  approximately 
at  least,  the  extent  of  the  attachment  of  a  sub-mucous 
fibroid  to  the  uterus.  The  first  step  in  making  this 
estimate  is  to  find  the  depth  of  the  uterine  cavity, 
which  is  generally  the  distance  from  the  external  os  to 
the  upper  border  of  the  base  of  the  tumor.  A  whale- 
bone probe,  the  best  instrument  for  this  purpose,  is 
passed  tip  to  the  fundus  uteri,  taking  care  that  it  will 
go  no  farther  by  introducing  it  once  or  twice  in  a  little 
different  direction,  as  the  point  is  liable  to  catch  in 
some  fold  of  tissue  ;  the  forefinger  is  then  placed  on  the 
probe,  close  to  the  cervix,  and  the  instrument  is  with- 
drawn. Making  a  little  allowance  for  the  curve  of  the 
probe  over  the  tumor,  the  instrument  is  laid  on  a  piece 
of  paper,  on  which  are  marked  the  points  corresponding 
to  the  tip  of  the  probe  and  the  external  os.  It  is  then 
re-introduced  along  the  opposite  surface  till  it  reaches 
the  tumor,  the  finger  placed  on  the  probe  next  to  the 
cervix,  and  again  withdrawn.  It  is  marked  along  the 
same  line  on  the  paper,  and  the  distance  between 
the  two  points  corresponding  to  the  tip  of  the  probe 
gives  a  fair  idea  of  the  thickness  of  the  base  of  the 
tumor ;  while  the  freedom  with  which  the  instrument 
will  move  laterally  over  the  growth  shows  the  breadth 
of  its  attachment. 

When  the  base  of  the  tumor  extends  low  down  in  the 
uterus,  it  often  encroaches  on  the  upper  part  of  the  cer- 
vical canal,  making  it  difficult  to  introduce  any  instru- 
ment, and  giving  rise  to  the  impression  that  there  is  a 
stricture  of  the  internal  os  ;  but  the  hard  margin  of  the 
growth  will  dispel  any  such  illusion. 


DIAGNOSIS  OF  FIBROID   TUMORS.  29 1 

Having  faithfully  tried  the  means  of  diagnosis  just 
described,  and  in  the  order  given,  i.e.,  abdominal  pal- 
pation, careful  bi-manual  examination  both  vaginal  and 
rectal,  and  the  whalebone  probe,  the  physician  may  be 
stilHn  doubt  as  to  whether  the  fibroid  projects  into  the 
uterine  cavity  sufficiently  to  warrant  operative  inter- 
ference through  the  vaginal  orifice,  when  the  tumor 
cannot  be  felt  presenting  in  the  cervical  canal.  Under 
these  circumstances,  it  is  necessary  to  dilate  the  cervix 
with  tents,'  or  a  steel  dilator; '  press  the  uterus  down 
from  above,  steady  it  below  with  volsellum  forceps  fixed 
in  the  cervix,  and  make  a  thorough  digital  examination 
of  the  uterine  cavity,  noting  the  attachment  and  pro- 
jection of  the  fibroid,  the  thickness  of  the  endometrium 
over  it,  as  well  as  pulsating  arteries,  if  any,  in  the  latter, 
which  would  be  divided  by  incising  the  capsule. 

On  introducing  the  finger,  what  seemed  to  be  a  large 
fibroid  may  prove  to  be  a  polypus  which  is  readily 
removed. 

Considerable  hemorrhage  may  follow  so  much  manip- 
ulation ;  but  irrigation  with  hot  water,  the  application  of 
iodine,  and  the  vaginal  plug  will  control  it.  The  patient 
must  be  put  to  bed,  and  kept  perfectly  quiet  till  all 
soreness  has  subsided. 

It  is  hardly  necessary  to  add  that  when  there  is 
considerable  pelvic  inflammation  present  with  a  fibroid 
tumor,  the  former  must  be  cured  before  it  is  safe  to 
attempt  any  operation  or  examination  which  the  patient 
cannot  readily  endure  without  ether. 

The  following  table  may  be  of  assistance  in  diagnosing 
the  variety  of  uterine  fibroid.^ 

*  See  chapter  on  Minor  Surgical  Gynjecology. 

^  See  also,  The  Differential  Diagnosis  of  the  Various  Forms  of  Fibroid 
Tumors  of  the  Uterus,  by  Alfred  Meadows,  M.D.,  F.R.C.P.,  British  ]\Iedical 
Journal,  p.  716,  vol.  ii.,  1883. 


292        BENIGN  GROWTHS  OF  THE   UTERUS. 


In  Sub-Mucous  Fibroids. 


The  hemorrhage  from 
the  uterus  is  quite  pro- 
fuse, the  more  so  in 
proportion  to  its  projec- 
tion into  the  uterine 
cavity. 

Pain  is  slight. 


If  there  is  a  hard,  firm, 
well-defined  tumor,  uni- 
form and  symmetrical  in 
shape,  which  has  been 
slowly  growing  for  three 
years  or  longer,  it  is  prob- 
ably a  fibrous  polypus,  or 
sub-mucous  fibroid. 


The  uterine  cavity  is 
enlarged,  filled,  and  dis- 
tended by  the  tumor, 
which  is  felt  by  the  finger 
after  dilatation  of  the  cer- 
vix. Its  attachments  can 
also  be  ascertained  by  the 
whalebone  probe. 

The  sub-mucous 
growths  have  more  cellu- 
lar, and  less  fibrous  tis- 
sue ;  they  grow  more 
rapidly  than  the  other 
forms. 


Interstitial  Fibroids. 


There  is  some  hem- 
orrhage, but,  as  a  rule, 
not  so  much  as  in 
sub-mucous  fibroids. 


Pain  is  more  severe 
than  in  the  former 
case.' 

The  growth,  in 
about  half  the  cases, 
is  on  the  posterior 
wall  of  the  uterus, 
which  is  not  symmet- 
rically developed,  but 
bulges  a  little  on  one 
side  at  the  site  of  the 
tumor. 


The  uterine  cavity 
is  deeper,  and  more 
or  less  tortuous  from 
the  bulging  of  the  tu- 
mor into  the  cavity. 


There  is  a  larger 
proportion  of  fibrous 
tissue,  and  the  tumor 
grows  more  slowly. 


Stib-Pt  ritotieal  Fibroids. 


There  may  be  slight 
orrhage,  but  more 

Lcn  none,  especially 
if  the  tumor  is  pedun- 
culated. 


heme 
often 


Pain  is  often  a  very 
marked  though  not  an 
invariable  symptom. 

Marked  asymmetry 
between  uterus  and 
tumor.  If  there  are 
several  developing  un- 
der the  peritoneum,  the 
uterus  has  a  knobby 
outline.  If  the  tumor 
be  pedunculated,  it  is 
movable  in  propor- 
tion to  the  length  of 
the  pedicle,  unless 
there  are  adhesions. 

The  uterine  cavity 
seldom  has  a  greater 
depth  than  three  inch- 
es, and  is  not  propor- 
tionate to  the  size  of 
the  tumor  unless  the 
latter  drags  the  uterus 
high  up,  and  so  length- 
ens the  cavity. 

The  fibrous  tissue 
is  most  marked  in  the 
sub-peritoneal.  The 
tumor  develops  slow- 
ly, and  is  hard,  having 
almost  a  cartilaginous 
feeling. 


'  Hewitt,  Diseases  of  Women,  vol.  ii.  p.  225. 


DIFFERENTIAL   DIAGNOSIS. 


293 


The  Differential  Diagnosis  of  Fibroid  Tumors  from  Preg- 
nancy, Exudation  in  Cellular  Tissue,  H^ematocele,  Col- 
lection of  F/eces. 

In  all  these  the  history  of  the  case,  its  duration,  and  present  symptoms, 
are  directly  opposite  to  those  common  to  uterine  fibroids. 


Pregnancy. 

Fibroid  Tumor. 

"  Tumor  "  of  short  duration. 

"  Tumor  "  elastic  to  touch. 

Amenorrhoea. 

Usual  symptoms  of  pregnancy. 

Of  long  duration. 
Tumor  very  hard. 
Uterine  hemorrhage. 
Symptoms  of  pregnancy  wanting. 

Cellnlitic  Exudation. 


Fibroid  Tumor. 


History  of  pelvic  inflammation. 

Exudation  sensitive  and  immov- 
able. 

Exudation  of  short  duration,  and 
distinct  from  the  uterus. 


No  history  of  pelvic  inflammation. 
Tumor  not  sensitive,  and  movable. 

Tumor  of  long  duration,  and  in- 
timately connected  with  the  uterus. 


Hcematocele. 

Fibroid  Tiimor. 

Formation  rapid,  and  attended  by 
symptoms  of  collapse. 

Fluctuation    and    immobility     of 
tumor. 

Formation  slow,  without  symp- 
toms of  collapse. 

No  fluctuation,  and  tumor  mov- 
able. 

Collection  of  Fceces. 

Fibroid  Tumor. 

It  is  left-sided. 
Short  duration. 
Can  be  indented  by  the  finger. 
Does  not  move  with  the  uterus. 
Symptoms   of   intestinal  obstruc- 
tion. 

Functions  of  uterus  not  affected. 

Not  limited  to  any  side. 

Long  duration. 

Cannot  be  indented. 

Moves  with  the  uterus. 

No  symptoms  of  intestinal  ob- 
struction. 

Marked  disturbance  of  the  uterine 
functions. 

294        BENIGN  GROWTHS  OF  THE   UTERUS. 


The  Differential  Diagnosis  of  Fibroid  Tumors  from  — 


Uterine  Flexions. 


Cancer. 


Ovarian  Tumors. 


The  sound  enters  the 
uterine  cavity  in  the 
centre  of  the  supposed 
tumor.  If  a  fibroid  is 
present,  the  sound 
passes  by  it  into  the 
uterine  cavity,  which 
does  not  correspond  to 
the  centre  of  the  tumor, 
but  lies  in  a  different 
direction. 


Cancer  of  the  fun- 
dus uteri  is  very  rare. 
Its  progress  is  much 
more  rapid  than  a 
fibroid.  The  d  i  s- 
charges  from  the  uter- 
us are  extremely  of- 
fensive. Pain  in  the 
pelvis,  and  fixation  of 
the  uterus,  are  quite 
constant  symptoms. 


Are  seldom  connected 
with  the  uterus.  There 
is  a  wave  of  fluctuation 
on  palpation,  and  their 
development  is  unilat- 
eral, and  more  rapid 
than  fibroids.  Puncture 
with  a  fine  needle  of  the 
aspirator  draws  off  a 
fluid  showing  the  char- 
acteristic granular  cells. 
Where  an  ovarian  tumor 
is  firmly  attached  to  the 
uterus,  differentiation  is 
often  impossible,  espe- 
cially if  the  tumor  be 
solid. 


The  Prognosis  is  fortunately  favorable,  so  far  as  life 
is  concerned.  Very  few  women  die  in  consequence, 
though  they  may  be  bedridden  for  a  long  time.  After 
the  menopause,  the  tumor  often  gradually  diminishes  to 
a  remarkable  degree,  and  ceases  to  be  a  source  of  dan- 
ger, though  its  presence  may  be  annoying.  Fibroid 
tumors  scarcely  ever  threaten  life,  except  from  the  loss 
of  blood  occasioned  by  them. 

The  Diet  is  important,  and  should  be  so  regulated  as 
to  nourish  the  system  in  spite  of  the  constant  drain. 
Milk,  eggs,  beef -juice,  or  raw  meat  extracts,  mutton- 
chop,  etc.,  are  important  articles  of  food.  Great  suc- 
cess in  the  treatment  of  uterine  fibroids  has  been 
claimed  by  Dr.  Salisbury's  method.'     It  consists  essen- 

'  See  article  by  Dr.  Ephraira  Cutter,  American  Journal  of  Obstetrics,  vol,  x. 
p.  562. 


DIET  FOR  FIBROID    TUMORS.  295 

tially  in  drinking  a  pint  of  hot  water  very  slowly  an 
hour  or  two  before  meals,  and  half  an  hour  before  re- 
tiring. The  object  of  this  is  to  cleanse  the  stomach 
before  eating  and  sleeping.  The  muscle  pulp  of  steak 
cut  from  the  centre  of  the  round,  is  broiled,  seasoned 
to  taste,  and  made  an  exclusive  article  of  diet.  All  the 
connective  tissue  is  removed  by  chopping  the  beef 
without  stirring  it.  The  fibrous  tissue  is  driven  down 
on  the  board,  while  the  muscle  pulp  is  occasionally 
scraped  off  the  surface  with  a  spoon  during  the 
chopping,  and  prepared  for  eating  as  above.  This 
treatment  must  be  rigidly  adhered  to  for  one  to  three 
years  to  be  successful.  It  has  received  much  com- 
mendation from  good  authorities,  such  as  Drs.  Graily 
Hewitt,  and  Marion  Sims,  while  others  have  never  seen 
any  benefit  result  from  it.  If  it  is  to  be  supposed  that 
these  tumors  develop  in  consequence  of  a  weak,  atonic 
condition  of  the  uterus,  it  would  appear  reasonable  that 
a  good  healthy  diet  without  fibrous  tissue  would  nourish 
the  uterus,  and  enable  it  to  discharge  its  functions  bet- 
ter with  a  minimum  supply  of  those  elements  entering 
into  the  formation  of  these  tumors.  Some  physicians 
believe  they  have  seen  benefit  from  wearing  an  earth- 
poultice,  or  from  the  application  of  myro-petroleum  to 
the  abdomen,  over  the  tumor,  for  a  number  of  con- 
tinuous  months. 

The  Treatment  of  fibroid  tumors  of  the  uterus  is  too 
often  unsatisfactory.  Except  where  life  is  in  actual 
danger,  or  the  tumor  easy  of  access,  as  in  sub-mucous 
fibroids  and  fibrous  polypi,  it  is  the  better  plan  to  adopt 
a  palliative  course,  rather  than  surgical  interference,  in 
the  hope  that  the  patient  will  tide  over  the  menopause. 
It  is  of  great  importance  to  correct  a  retroversion  or 
prolapse  of  the  uterus,  as  this  favors  congestion,  and  a 
much  more  rapid  growth  of  the  tumor. 


296        BENIGN  GROWTHS  OF  THE   UTERUS. 

Uterine  hemorrhage  is  the  symptom  which  is  the 
most  dangerous  to  the  patient,  the  most  difficult  and 
most  important  to  control.  This  can  be  accomplished 
in  many  cases  by  a  carefully  selected  remedy,  the  hot- 
water  douche,  the  local  application  of  the  tincture  of 
iodine  or  the  perchloride  of  iron  to  the  uterine  cavity, 
the  vaginal  plug,  or  a  combination  of  these  measures. 
On  the  least  appearance  of  a  show,  the  patient  should 
lie  down  with  the  hips  raised  a  little,  and  remain  in 
that  position  till  the  flow  ceases.  In  the  interval 
betw^een  the  periods,  moderate  exercise  in  the  open 
air,  sun-baths,  and  bathing  followed  by  vigorous  fric- 
tion of  the  skin,  are  excellent  to  maintain  the  general 
health.  There  should  be  no  constriction  of  the  waist, 
or  pressure  on  the  abdominal  organs  by  the  clothing, 
as  it  interferes  with  free  venous  circulation,  and 
thus  promotes  hemorrhage.  The  tendency  to  consti- 
pation can  be  obviated  by  regulating  the  diet ;  and 
an  occasional  collection  of  faeces  removed  by  enemas 
given  to  the  patient,  if  necessary,  in  the  knee-chest 
position.  The  mineral  waters  of  Kreutznach,  in  Rhen- 
ish Prussia,  are  quite  celebrated  for  the  treatment  of 
uterine  fibroids.' 

Electrolysis^  has  had  its  advocates  from  time  to  time, 
but  has  not  been  generally  accepted  as  a  reliable  method 
of  treatment.  Dr.  Apostoh,^  of  Paris,  is  enthusiastic 
in  its  favor.     He  employs  a  strong  current  (100  milli- 

'  In  an  excellent  article  on  Carlsbad :  Its  Springs,  their  Physiological  Action 
and  Indications,  Dr.  Th.  Kafka  states  that  fibroid  tumors  often  disappear  as  an 
apparent  result  of  taking  the  water.  —  Monthly  Horn.  Review,  p.  274,  May  i, 
1S85. 

2  An  interesting  article  on  Electricity  in  Gynaecology,  and  a  report  of  three 
fibroid  tumors  successfully  treated  by  it,  will  be  found  in  the  Journal  of  the  Ameri- 
can Medical  Association,  July  17  and  24,  18S6.  See  also  Electrolysis  in  the 
Treatment  of  Uterine  Fibroids,  by  Dr.  Franklin  H.  Martin,  in  the  same  journal, 
p.  78,  Jan.  15,  1887. 

3  Du  Traitement  Electrique  des  Tumeurs  de  I'Uterus,  1884. 


ELECTRICITY  FOR    UTERINE    FIBROIDS.      297 

amperes)  without  puncturing  any  tissue.'  The  positive 
pole,  made  of  platinum,  is  applied  within  the  uterus 
when  there  is  uterine  hemorrhage.  Dr.  Engleman  ^ 
combines  this  method  with  puncture  of  the  tumor 
through  the  uterine  cavity.  Great  success  is  claimed 
for  both  these  methods.  Dr.  Freeman  ^  of  Brooklyn 
also  speaks  highly  of  electricity.  He  uses  a  strong 
current.  The  needle  of  one  pole  is  thrust  well  into  the 
tumor,  through  the  abdominal  wall,  while  the  other  is 
introduced  within  the  uterine  cavity.  As  the  vitality 
of  fibroid  tumors  is  easily  destroyed  by  slight  injuries, 
Dr.  John  Butler  produced  a  slough  on  the  mucous  sur- 
face by  electrolysis,  which  caused  the  subsequent  death 
and  disorganization  of  the  growth.  Plausible  as  this 
method  may  seem,  it  is  open  to  the  grave  objection 
of  the  liability  of  the  patient  to  septic  infection  from 
the  decomposing  and  purulent  material  in  the  uterine 
cavity. 

When  the  tumor  is  sub-mucous,  or  has  a  distinct 
pedicle,  and  especially  if  it  presents  in  the  cervical 
canal  or  projects  from  it,  there  is  little  danger  in 
removing  it,  which  ought  to  be  done  without  waiting 
till  there  is  extreme  anaemia  from  loss  of  blood.-^  This 
can  be  accomplished  by  the  ecraseur  or  persistent 
traction,  and  the  use  of  scissors  or  Thomas'  spoon  saw.s 
A  drainage  tube  should  be  inserted  in  the  uterine 
cavity  afterward  to  insure  a  free  escape  of  decomposing 
fluids,  and  prevent  septicaemia. 

'  Dr.  Carlet  has  reported  ninety-four  fibroids  treated  in  this  way ;  published  by 
Octave  Doin,  Paris,  1884. 

2  Transactions  of  the  American  Gynaecological  Society,  1886;  and  American 
System  of  Gynaecology,  vol.  i.  p.  398. 

3  Discussion  on  Electricity  in  Gj'naecology,  in  the  New- York  Academy  of 
Medicine.  —  The  Medical  Record,  vol.  ii.  p.  554,  1885. 

'■  See  Enucleation  of  Fibroid  Tumors.  Doran,  Gynaecological  Operations, 
p.  307,  1887. 

5  Emmet's  Principles  and  Practice  of  Gynaecology,  p.  566,  1884. 


298.       BENIGN  GROWTHS  OF  THE    UTERUS. 

The  hypodermic  injection  of  ergot '  has  been  much 
used  to  check  the  hemorrhage,  and  is  said  to  be  very- 
useful  in  some  cases,  particularly  for  those  tumors  pro- 
jecting well  into  the  uterine  cavity  after  the  cervical 
canal  has  been  and  is  kept  dilated.  Dr.  Winckel^  joins 
many  physicians  in  commending  this  drug,  but  warns 
the  profession  against  its  use  in  large  doses,  especially 
in  anaemic  patients.  The  use  of  ergot  has  also  been 
combined  with  incision  of  the  capsule,  in  hopes  that  the 
tumor  might  become  pedunculated,  and  more  accessible 
for  removal.  This,  however,  is  often  impracticable  in 
interstitial  fibroids. 

Next  to  ergot.  Dr.  Winckel  ^  recommends  hydrastis 
canadensis  in  twenty-five-drop  doses  of  the  fluid  extract 
three  or  four  times  a  day ;  and  if  gastric  disorder 
ensue,  to  use  thirty-seven  and  a  half  grains  of  the  dry 
extract  in  pill  form  instead  of  the  fluid  extract.  These 
may  be  considered  large  doses.  Fellner  believed  it 
caused  uterine  contractions,  and  increased  the  blood 
pressure.  Schatz,'^  who  introduced  the  remedy,  thinks 
it  causes  contraction  of  the  capillary  vessels  instead 
of  the  uterus,  and  differs  from  ergot   in  this  respect. 

'  Hildebrandt,  American  Journal  of  Obstetrics,  November,  1872  ;  and  Byford, 
Transactions  of  the  American  Gynaecological  Society,  vol.  i.  p.  168. 

'  E.  Evetzky  collected  the  records  of  223  fibroid  tumors  treated  by  the  hypo- 
dermic injection  of  ergot. 

In  42  cases  the  tumors  were  absorbed. 

In    9  cases  the  tumors  were  expelled. 

In  71  cases  the  tumors  diminished  in  size,  and  the  symptoms  were  relieved. 

In  51  cases  no  impression  was  made  in  size  or  density,  but  the  symptoms 
improved. 

In  49  cases  no  benefit. 

I  case  died  in  consequence. 

—  New  York  Medical  Journal,  March,  1882,  p.  231. 
Though  the  results  may  appear  favorable,  the  author  must  assert  that  ergot  often 
fails  to  benefit  patients  suffering  from  fibroid  tumors. 

^  Diseases  of  Women,  Am.  ed.,  p.  427,  1887. 

3  Ibid.,  p.  428. 

■*  Centralblatt  fiir  Gynakologie,  No.  46,  1883. 


CASTRATION  FOR   UTERINE  FIBROIDS.      299 

Both  Wilcox'  and  Jermans^  have  found  it  very  useful 
for  uterine  hemorrhage  from  other  causes  than  the 
presence  of  fibroids. 

In  1872,  Professor  Hegar'  in  Germany,  and  Dr.  Bat- 
tey  ^  of  Georgia,  advocated  removal  of  the  ovaries  for 
the  relief  of  various  affections,  among  them  being  uter- 
ine fibroids  accompanied  by  profuse  hemorrhage.  As 
this  is  one  of  the  conservative  surgical  measures,  it  has 
found  some  favor.  Dr.  Wiedow  s  has  collected  the 
records  of  one  hundred  and  forty-nine  operations  of 
castration  for  uterine  fibroids.  Fifteen  of  them  ended 
fatally.  In  seventy-six  cases,  the  final  results  were  as 
follows  :  — 

Atrophy  of  the  tumors  and  menopause     .     .  54  cases. 

Occurrence  of  the  menopause  only      ...  7      " 

Atrophy  of  tumors  only 2      " 

Diminution  of  bleeding  and  atrophy    ...  6      " 
Menopause  for  three   months,  followed   by 

expulsion  of  the  tumor •.     .  i  case. 

Irregular,  slight  hemorrhages 2  cases. 

Irregular,  severe  hemorrhages i  case. 

Immediate  good  results  followed  by  severe 

bleeding  and  growth  of  the  tumors  ...  3  cases. 
Mortality  of  the  one  hundred  and  forty-nine 

operations 10  per  cent. 

Many  cases  continue  to  have  the  same  pains  and 
other  symptoms  due  to  uterine  fibroids  after  the 
operation  as  before.  Dr.  Gusserow  believes  castration 
"  leads  with  great  certainty  to  an  arrest  of  hemorrhage, 

'  New  York  Medical  Journal,  p.  199,  Feb.  19,  1887. 

2  Centralblatt  fiir  Gynakologie,  No.  35,  1887. 

3  Compare  Hegar  and  Kaltenbach,  Operative  Gynakologie,  p.  334,  1881,  for  a 
careful  history  and  description  of  the  operation. 

*  American  Journal  of  Obstetrics,  January,  1880. 
5  Archiv  fiir  Gynakologie,  bd.  xxv. 


300        BENIGN  GROWTHS  OF  THE   UTERUS. 

provided  the  uterine  tumors  are  not  too  large,  and  not 
in  a  condition  of  cystic  degeneration  ; "  besides,  it  is 
a  much  safer  operation  than  extirpation  of  the  tumor. 
Dr.  Homans  of  Boston  has  found  that  the  bleeding 
may  continue  just  as  severe  after  castration ;  and  Dr. 
Winckel '  still  considers  this  operation  stib  jiidice  for 
unoperative  myomata  with  a  mortality  of  fifteen  per 
cent,  and  a  failure  for  the  desired  result  in  twenty 
per  cent  of  the  cases  which  recover. 

The  operation  should  not  be  performed  when  the 
hemorrhages  do  not  correspond  to  menstrual  periods, 
or  if  the  menopause  has  arrived.  It  is  better  adapted 
to  small  and  rapidly  growing  tumors  accompanied  by 
profuse  hemorrhages,  than  to  large  fibroids.  In  the 
latter,  the  ovaries  are  sometimes  found  and  removed 
only  with  great  difficulty. 

Prochownik-  has  had  better  results.  He  reports 
twenty-two  cases  of  castration  without  a  death.  Twelve 
of  these  were  for  fibroid  tumors,  and  in  these  the 
results  were  remarkable.  The  tumors  diminished  in 
size ;  pain  and  bleeding  ceased.  All  of  these  growths 
would  have  otherwise  required  supra-vaginal  amputa- 
tion, or  enucleation  from  the  uterine  walls  or  pelvic 
connective  tissue.  It  is  interesting  to  note  that  the 
results  of  castration  for  neuroses  complicating  sexual 
disorders  were  not  so  good  when  healthy  ovaries  were 
removed.  Dr.  Tait  ^  advocates  removal  of  the  Fallopian 
tubes  with  the  ovaries,  and  has  met  with  remarkable 
success.  His  unusually  low  rate  of  mortality  must 
be  largely  attributed  to  his  remarkable  skill  as  a  sur- 

1  Diseases  of  Women,  Am.  ed.,  p.  437,  1887. 

2  Beitrage  zm-  Kastrationsfraga,  Archiv.  fiir  Gynakologie,  Bd.  xxix.  Heft  2. 

3  The  Modern  Treatment  of  Uterine  Myomata,  British  Medical  Journal,  vol.  ii. 
p.  287,  1S85.  In  fifty-eight  consecutive  cases,  all  recovered  from  the  operation.  In 
the  fifty  cases  reported  in  this  article,  all  were  very  much  relieved  or  cured  by  the 
operation  excepting  one,  who  was  afterwards  cured  by  removal  of  the  tumor. 


OPERATIONS  FOR   UTERINE  FIBROIDS.      Z0\ 

geon.  Unfortunately,  it  will  not  always  arrest  the 
hemorrhage,  nor  can  the  ovaries  always  be  found. 

The  removal  of  sub-peritoneal  fibroids  by  abdominal 
section  is  a  formidable  operation,'  but  has  been  per- 
formed with  considerable  success  by  Drs.  ^  Schroeder  ^ 
and  Martin  ^  in  Berlin,  and  Bantock  5  in  London.  Dr. 
Sanger^  has  recently  modified  the  operation  for  supra- 
vaginal amputation  of  the  uterus. ^  Removal  of  the 
entire  uterus  for  fibrous  tumors  has  been  attended  with 
so  high  a  rate  of  mortality,  that  the  operation  has  not 
met  with  much  favor.^ 

Baker  Brown  introduced  the  operation  of  incising 
the  cervical  canal  and  the  os  internum,  as  well  as  the 
capsule  of  the  fibroid,  when  it  is  accessible.  This 
relieves  the  hemorrhage  in  some  cases,  when  the  tumor 
is  well  down  in  the  os  internum,  and  is  practised  by 
many  gynaecologists. 

The  medical  treatment  is  considered  at  the  close  of 
this  chapter. 

'  Dr.  H.  R.  Bigelow  has  made  an  elaborate  study  of  gastrotomy  for  uterine 
fibroids,  with  complete  statistical  tables,  in  the  American  Journal  of  Obstetrics, 
1883-84. 

^  For  a  description  of  their  operations,  see  Myomotomy,  by  Dr.  Carl  Schroeder, 
British  Medical  Journal,  p,  714,  vol.  ii.  1883. 

3  Dr.  Hofmeyer,  first  assistant  to  Dr.  Schroeder,  has  made  an  excellent  study 
of  this  operation  as  performed  in  Berlin,  in  Die  Myomotomie,  1S84,  which  is 
reviewed  by  Dr.  Wiener  in  the  Centralblatt  fiir  Gynakologie,  No.  11,  1S86. 

*  Martin,  Pathologie  und  Therapie  der  Frauen-krankheiten,  1887. 

5  A  good  description  of  Bantock's  method  of  supra-vaginal  hysterectomy  can 
be  found  in  Doran's  Gyn£ecological  Operations,  p.  287,  1SS7. 

^  Zur  Technik  der  Amputation  Uteri  myomatosi  supra-vaginalis  (Intraperitone- 
ale  Abkapselung,  elastische  Dauerligatur  des  Uterusstumpfes).  Dr.  M.  Sanger : 
Ceittralblatt  fiir  Gyniikologie,  No.  44,  p.  718,  18S6. 

^  Compare  Hysterectomy  for  Myoma.  Greig  Smith,  Abdominal  Surgery, 
p.  211,  18S7. 

^  The  opinion  of  so  high  an  authority  as  Dr.  Thomas  Keith  is  of  importance. 
He  considers  the  operation  a  very  hazardous  one,  which  should  be  considered  the 
last  resort.  Compare  his  Contributions  to  the  Surgical  Treatment  of  Tumors  of 
the  Abdomen,  Part  I.,  1885. 


302        BENIGN  GROWTHS  OF  THE   UTERUS. 

FIBRO-CYSTIC    TUMORS. 

These  are  quite  rare,  and  chiefly  interesting  for 
their  close  resemblance  to  ovarian  tumors.  It  is  quite 
probable  that  very  many  of  those  growths  described  as 
fibro-cystic  tumors  of  the  ovary  really  originated  from 
muscular  fibres  in  or  near  the  uterus,  and  not  from  the 
ovary.  True  cysts  of  the  uterus  are  extremely  rare, 
and  all  fibro-cystic  growths  are  the  result  of  a  cystic 
transformation  in  fibroid  tumors,  which  may  take  place 
in  various  ways,  but  chiefly  from  separation  between 
muscular  fibres,  the  collection  of  serum  in  the  space 
thus  formed,  and  the  fusion  of  many  cavities  into  one. 
This  is  most  common  in  sub-peritoneal  varieties,  and 
less  frequent  in  the  interstitial  ones. 

Their  symptoms  are  the  same  as  those  accompanying 
fibroids  of  the  same  size. 

The  differential  diagnosis  is  extremely  difficult,  and 
often  impossible.  The  most  distinctive  feature  is  a 
localized  obscure  sensation  of  fluctuation  without  the 
hardness  of  a  fibroid  tumor.  If  an  aspirator  be  used,  a 
variable  amount  of  fluid  is  drawn  off,  which  leaves  solid 
portions  of  the  tumor  in  the  abdomen  ;  this  fluid  coagu- 
lates spontaneously,  and  closely  resembles  the  liquor 
sanguinis ;  under  the  microscope '  it  shows  a  few  epi- 
thelial cells,  oil  globules,  and  fibre  cells,  characteristic 
of  the  structure  in  which  the  cyst  originated.  The 
granular  ovarian  cell,  or  Drysdale's  corpuscles,  peculiar 
to  ovarian  tumors,  are  not  present.  The  microscopic 
appearance  of  the  fluid  is  the  best  guide  in  cases  of 
doubtful  diagnosis.  Emptying  the  cyst  by  trocar  or 
aspirator  has  not  been  attended  with  much  success  as  a 
method  of  treatment.  As  an  almost  invariable  rule,  they 
must  be  treated  in  the  same  way  as  uterine  fibroids.    - 

'  Atlee,  Ovarian  Tumors,  p.  263. 


UTERINE  POLYPI.  303 

Uterine  Polypi  (adenoma)  are  divided  into  three 
classes  :  cellular,  glandular,  and  that  known  as  fungoid 
endometritis.  The  first  is  the  most  frequent,  and  it  is 
covered  with  mucous  membrane,  which  gives  to  it  the 
common  name  of  mucous  polypus.  It  is  generally 
situated  near  the  internal  os,  and  seventy  per  cent  of 
the  cases  occur  between  fifty  and  seventy  years  of  age. 
Its  texture  is  soft  and  vascular  like  a  nasal  polypus. 

The  glandular  polypus  consists  in  a  hypertrophy  of 
the  cervical  follicles  or  Nabothian  glands,  and  is  com- 
monly associated  with  laceration  of  the  cervix.  The 
various  enlarged  follicles  are  united  to  one  another,  so 
that  the  polypus  may  resemble  an  hydatiform  mole. 

Fungoid  (polypoid)  endometritis '  has  been  mentioned 
in  a  previous  chapter,  but  further  consideration  of  it  is 
necessary.  It  may  be  merely  a  hypertrophy  of  the 
membrane  lining  the  uterine  cavity  with  moderate 
dilatation  of  the  utricular  glands,  and  affect  the  entire 
membrane  ;  or  it  may  occur  in  localized  spongy  patches 
like  soft,  flat,  wart-like  excrescences,  which  are  attached 
by  a  broad  base  to  the  walls  of  the  uterine  cavity.  In 
more  rare  cases,  the  utricular  glands  of  the  uterus  par- 
ticipate more  actively  in  the  new  formation,  leading  to 
diffuse  glandular  development  in  the  mucous  membrane. 
This  is  known  as  diffuse  adenoma  of  the  uterus. 

Polypi  are  liable  to  develop  from  any  condition  caus- 
ing a  passive  congestion  of  the  lining  membrane  of  the 
uterine  cavity,  and  especially  from  chronic  endometri- 
tis. They  vary  in  size  from  a  pea  to  a  hen's  Q,g^ ;  and 
all  three  forms  have  symptoms  common  to  one  another 
and  to  uterine  fibroids,  such  as  uterine  hemorrhage, 
watery  discharges  from  the  uterus,  leucorrhoea,  pelvic 
pain,  etc.  Pain,  however,  is  generally  absent  in  pedicu- 
lated  polypi,  which  lie  in  the  external  os  or  protrude 

'  Olshausen  :  Archiv  fiir  Gynakologie,  Bd.  viii,  p.  97. 


304        BENIGN  GROWTHS   OF   THE    UTERUS. 

from  it.  It  is  often  a  matter  of  surprise  that  so  much 
trouble  can  come  from  such  a  small  growth.  The 
presence  of  a  polypus  no  larger  than  a  pea  may  excite 
profuse  menorrhagia,  leucorrhoea,  etc.,  which  'only 
ceases  when  the  growth  is  removed.  One  of  these 
little  tumors  has  been  known  to  act  like  a  little  ball 
valve  in  the  cervical  canal,  causing  both  dysmenorrhoea 
and  sterility. 

The  Diagnosis  is  easy  when  the  growth  can  be  seen 
or  felt  presenting  in  the  external  os  uteri ;  but  when  it 
lies  within  the  uterine  cavity,  it  is  a  difficult  matter,  and 
the  presence  of  a  polypus  can  only  be  ascertained  by 
dilating  the  cervical  canal,  and  exploring  the  uterine 
cavity  with  the  finger. 

Prognosis. — The  proneness  of  all  forms  of  uterine 
polypi  to  recur  after  removal,  and  the  enfeeblement  of 
the  system,  due  to  the  hemorrhage,  leucorrhoea,  and 
pain  caused  by  these  growths,  have  led  some  observers 
to  believe  them  to  be  of  a  malignant  character.  This 
applies  more  especially  to  endometritis  fungosa  with 
diffuse  development  of  the  utricular  glands.  Indeed, 
specimens  of  this  growth  removed  by  the  curette  have 
been  examined  by  expert  microscopists,  and  pro- 
nounced, without  hesitation,  to  be  malignant,  which 
the  subsequent  history  of  the  case  proved  to  be  an 
incorrect  diagnosis. 

Adenoma  and  carcinoma  are  sometimes  found  in  the 
same  specimen,  which  Ziegler  terms  adeno-carcinoma. 
This  has  led  some  writers  quite  recently  to  believe  that 
an  adenoma  may  develop  into  a  carcinoma.  At  all 
events,  adenoma  may  be  considered  as  on  the  boundary- 
line  between  benign  and  malignant  disease,'  which  can 
be  determined  only  by  the  subsequent  history  of  the 
case,  as  the  microscope  does  not  give  us  sufficient  light 

'  Winckel:  Diseases  of  Women,  p.  358,  18S7. 


TREATMENT  OF  POLYPI.  305 

on  the  subject.'  While  circumscribed  pediculated  pol- 
ypi may  recur  frequently,  they  are  not  at  all  likely  to 
assume  a  malignant  character.  The  same  cannot  be 
said,  however,  concerning  the  endometritis  fungosa,  i.e., 
general  or  local  hyperplasia  of  the  mucous  membrane 
of  the  uterine  cavity,  involving  the  utricular  glands  as 
described  above.  The  frequency  of  recurrence,  the 
extent  of  the  disease,  and  the  depth  it  penetrates  into 
the  uterine  v^all,  indicate  malignancy  in  proportion  to 
the  prominence  of  these  symptoms  ;  while  Dr.  Goodell  ^ 
adds  an  important  clinical  observation,  that  "  malignant 
diseases  of  the  endometrium  are  usually  found  in  old 
maids  and  in  sterile  women,  while  malignant  diseases 
of  the  cervix  almost  always  occur  in  women  who  have 
borne  children." 

The  Treatment  is  obvious.  When  one  of  these  little 
growths  is  seen  in  the  cervical  canal,  seize  the  pedicle 
with  dressing  forceps,  and  twist  it  off.  In  rare  instances 
it  may  be  so  large  that  an  ecraseur  must  be  used. 
Nearly  all  the  small  intra-uterine  polypi  can  be  crushed 
down  and  removed  by  the  dull  wire  curette  which  will 
do  no  harm  ;  and  if  a  small  polypus  be  suspected,  this 
curette  had  better  be  used  instead  of  dilating  the  canal. 
If  both  this  and  Recamier's  curette  fail,  the  cervix  must 
be  dilated,  and  the  noose  of  an  ecraseur  passed  over 
the  pedicle  of  the  tumor  to  remove  it.  This  latter 
operation  is  subject  to  the  same  risks  as  the  removal  of 
a  sub-mucous  fibroid,  and  is  not  to  be  performed  without 
due  consideration.  It  is  a  cardinal  rule,  that  all  manip- 
ulations of  any  kind  in  the  pelvis  must  be  carefully 
avoided  when  there  are  any  symptoms  of  pelvic  inflam- 
mation. These  growths  do  not  cease  to  develop  after 
the  climacteric,  and  are  liable  to  return  after  removal. 

^  Gusserow:  New  Growths  of  the  Uterus,  p.  350,  1887. 
^  Goodell :  Lessons  in  Gynaecology,  p.  316,  18S7. 


3.o6        BENIGN  GROWTHS   OF   THE    UTERUS. 

Only  a  short  time  ago  the  writer  removed  a  glandular 
polypus  from  an  old  lady  who  said  she  was  seventy-two 
years  old. 

In  endometritis  fungosa,  the  cervix  must  be  dilated, 
unless  it  is  sufficiently  relaxed  from  the  frequent 
hemorrhages,  and  all  the  diseased  tissue  be  thoroughly 
removed  with  Recamier's  curette.  The  uterine  cavity 
should  then  be  injected  with  iodine  or  the  undiluted 
per-chloride  of  iron,  taking  great  care  that  the  cervical 
canal  is  sufficiently  patulous  to  allow  a  free  escape  of 
the  fluid  injected.  In  cases  of  frequent  recurrence, 
when  the  above  treatment  has  failed,  fuming  nitric  acid, 
or  the  solid  nitrate  of  silver,  has  been  used.  This  very 
severe  treatment  should  not  be  employed  until  all  other 
remedies  have  failed,  except  removal  of  the  uterus.  The 
latter  is  best  done  by  the  operation  known  as  vaginal 
hysterectomy,'  and  is  indicated  if,  in  spite  of  all  other 
measures,  the  growth  becomes  of  a  malignant  character, 
and  nests  of  epithelial  cells  and  atypical  formations  are 
observed  under  the  microscope. 

The  Medical  Treatment  of  uterine  fibroids,  fibro-cystic 
tumors,  and  uterine  polypi,  is  considered  under  one 
heading,  as  the  same  remedies  apply  to  any  one  of 
them  if  indicated  by  the  symptoms.  Unfortunately,  it 
is  doubtful  whether  any  remedies  have  any  power  of 
directly  causing  the  tumor  to  be  absorbed,  or  expelled 
from  the  uterus.  The  growth  and  the  attending  hem- 
orrhage are  sometimes  checked  or  arrested,  so  that  the 
patient  passes  safely  through  the  climacteric,  and  suf- 
fers little  inconvenience  afterward.  Cases  are  reported 
where  the  tumors  diminished  in  size  under  treatment ; 
but  as  many  of  these  are  at  the  menopause,  it  is  a 
question  to  which  the  result  was  due.     Even  if  there  be 

'  Compare  A.  Martin,  Frauenkrankheiten,  1887;  and  Greig  Smith,  Abdominal 
Surgery,  p.  185,  18S7. 


THERAPEUTICS.  307 

no  perceptible  improvement  in  the  actual  size  of  the 
tumor,  if  the  pain  and  hemorrhage  can  be  sufficiently 
controlled  by  remedies  till  after  the  climacteric,  it  is  a 
far  better  course  to  pursue  than  to  submit  the  patient 
to  a  dangerous  operation.  Consult  also  the  chapter  on 
Menorrhagia  and  Metrorrhagia. 

THERAPEUTICS. 

Belladonna.  Plethoric  patients.  Much  bearing- down  in 
the  pelvis  (Lil.  tig.,  natr.  raur.,  plat.,  sepia).  Menses  too  early 
and  too  profuse  ;  bright  red  blood  ;  or  thick,  decomposed,  dark 
red  blood.  Tlie  blood  feels  hot  to  the  iarts ;  throbbing  and 
sensitiveness  to  the  touch  in  the  pelvic  organs. 

II  Calcarea  iodide.'  Patients  having  a  strumous  diathesis. 
Menses  too  early,  too  long,  and  too  profuse  ;  milky  leucorrhcea, 
with  itching  and  burning  ;  acidity  of  the  stomach  ;  profuse  per- 
spiration in  the  morning  (Quinise  sulph.,  nitric  ac,  phos.,  rhus 
tox.)  and  on  slight  exertion.  It  must  be  prepared  fresh,  and 
kept  in  a  blue  glass  bottle,  out  of  the  light.  The  writer  has 
had  two  cases  in  which  calcarea  carb.,  3X.  trit.,  seemed  to 
diminish  the  size  of  the  tumor  to  a  marked  degree.  One  was 
about  the  size  of  a  cocoanut,  in  the  left  side  of  the  pelvis,  and 
seemed  to  partake  of  the  characteristics  of  both  fibroid  and 
ovarian  tumors,  though  the  symptoms  pointed  to  the  former 
rather  than  the  latter.      The  second  one  was  a  distinct  sub- 

'  The  indications  for  tliis  remedy  in  tlie  treatment  of  uterine  fibroids  are  not 
well  understood.  It  seems  to  be  more  often  effectual  in  causing  a  gradual  diminu- 
tion of  the  tumor  than  any  other  remedy,  and  in  doses  too  small  to  act  on  the 
theory  of  calcification  of  the  growth  and  interference  with  its  nutrition.  It  is  sig- 
nificant that  the  most  celebrated  mineral  waters  for  the  cure  of  fibroids  contain  a 
large  amount  of  lime  salts.  Good  results  have  been  reported  from  the  third  decimal 
trituration.  It  has  also  been  recommended  in  the  shape  of  ten  grains  to  a  pint  of 
water,  a  teaspoonful  to  be  taken  after  each  meal,  gradually  increasing  to  a  table- 
spoonful.  This  may  act  very  similar  to  the  chloride  of  calcium  in  possibly  causing 
a  calcareous  degeneration  in  the  tumor ;  but  as  it  has  been  found  that  the  coats  of 
the  arteries  are  also  likely  to  undergo  the  same  degeneration,  the  remedy  may 
become  a  dangerous  one.  It  seems  quite  probable  that  it  can  influence  the  nutri- 
tion or  development  of  these  tumors  in  a  certain  number  of  cases,  without  being 
given  in  sufficient  quantity  to  produce  the  degeneration  alluded  to. 


3q8      benign  growths  of  the  uterus. 

peritoneal  fibroid,  about  the  size  of  a  man's  fist,  on  the  anterior 
wall  of  the  uterus.  In  less  than  two  years  the  growth  had  so 
decreased  in  size,  it  could  hardly  be  found  by  the  most  careful 
bi-manual  examination. 

It  is  by  no  means  claimed  that  calcarea  is  the  sovereign 
remedy  for  fibroids.  Only,  it  seems  one  of  the  most  promising 
ones,  if  its  use  is  persisted  in  long  enough,  but  there  are  very 
many  cases  in  which  it  will  be  of  no  service. 

China.  Is  excellent  for  the  prostration  accompanying  the 
loss  of  blood ;  also,  for  uterine  hemorrhage  of  dark  blood  and 
clots,  fainting,  and  muscular  twitching. 

I  Ferrum.  Ansemia  from  loss  of  blood;  stinging  head- 
ache and  ringing  in  the  ears  before  the  menses ;  flow  too  pro- 
fuse, passive  and  dark,  accompanied  by  labor-hke  pains  in  the 
abdomen,  and  a  glowing  red  face. 

Platina.  Menses  too  early,  mid  too  profuse  ;  flow  dark  and 
clotted,  with  much  bearing-down  and  pinching  pains  in  the 
abdomen ;  nymphomania ;  painful  sensitiveness,  and  constant 
pressure  in  the  hypogastric  region ;  the  body  feels  cold,  except- 
ing the  face. 

Sabina.  Menses  too  early,  too  profuse,  and  last  too  long ; 
hemorrhage  from  the  uterus  in  paroxysms ;  worse  from  motion  ; 
blood  dark  and  clotted,  and  sometimes  offensive ;  with  pain 
from  back  to  pubis. 

II  Secale.  This  should  be  freshly  prepared,  and  will  be 
found  to  act  best  in  the  tincture,  or  lower  dilutions.  Menses 
too  profuse,  and  last  too  long ;  uterine  hemorrhage,  worse 
from  least  motion  ;  discharge  thin  and  black  ;  black,  lumpy,  or 
brown  fluid,  and  very  foetid  ;  pains  in  the  uterus  of  an  expul- 
sive character. 

I  Trilline.  Metrorrhagia,  especially  at  the  chmacteric,  flow 
returns  every  two  weeks.  It  may  be  active  or  passive,  and  is 
accompanied  by  pain  in  the  back,  and  cold  limbs.  Dr.  Lud- 
1am  speaks  highly  of  this  remedy,  for  the  hemorrhages  resulting 
from  fibroid  tumors,  and  thinks  it  most  useful  in  those  cases 
where  the  muscular  fibres  of  the  uterus  have  been  decidedly 
developed  by  pregnancy  or  otherwise. 


THERAPEUTICS.  309 

The  following  remedies  may  be  consulted  for  further 
reference :  — 

Ars.,  aurtiin,^  carb.  veg.,  cinnamon,  conium,  crocus, 
cyclamen,  gossypium,^  erigeron,  hamamelis,  iodine, 
lach.,  lycop.,  mag.  mur.,  mercurius  sol.,  nitric  ac,  phos., 
sepia,  silicea,  sulph.,  thuja,  ustilago,  vinca  major.^ 

'  Dr.  Schwabe  considers  this  the  chief  remedy,  especially  the  aur.  mur.  natr., 
to  promote  resorption.  Like  other  remedies  it  must  be  used  perseveringly, — 
Lehrbuch  der  Horn.  Therapie,  3d  ed.,  vol.  ii.  p.  992. 

^  Dr.  Garrigues  recommends  the  cotton  root  for  the  treatment  of  the  hemor- 
rhage.—  Medical  Record,  vol.  ii.  p.  554,  1885. 

3  Recommended  by  Dr.  Meadows  for  the  hemorrhage  of  fibroid  tumors.  — 
Lancet,  July  12,  1873. 


3IO    MALIGNANT  DISEASE  OF  SEXUAL  ORGANS. 


CHAPTER    XXI. 


MALIGNANT    DISEASE    OF    THE    SEXUAL    ORGANS. 


BY  the  term  malignant  disease  is  meant  a  neoplasm 
which  returns  after  extirpation,  and  tends  with 
more  or  less  rapidity  to  a  fatal  termination.  Extensive 
destruction  of  tissue  characterizes  them  all.  They  may 
be  classified  as  follows  :  — 


Malignant 
growths. 


f    Non-cancerous 


Cancer ' 


I  Sarcoma,  or  recurrent  fibroid. 
I  Corroding  ulcer. 
f  Epithelioma,      papilloma,     or 
I       cauliflower  excrescences. 
\  Scirrhous  or  hard. 

Medullary,  encephaloid,  or  soft. 

Colloid.    ■ 


The  question  of  local  or  constitutional  origin  of  the 
disease  will  not  be  discussed  here,  nor  the  details  of  its 
pathology,  as  both  lie  outside  the  scope  of  this  work, 
and  can  be  found  in  more  voluminous  treatises.  Malig- 
nant disease  of  the  sexual  organs  presents  the  same 
characteristics,  and  is  subject  to  the  same  pathological 
changes,  as  in  any  other  part  of  the  body.  Women  are 
much  more  subject  to  it  than  men,  the  married  more  than 
the  single,  and  the  uterus  more  than  any  other  locality. 

Unfortunately  most  of  these  cases  are  not  seen  by 
the  physician  till  the  disease  has  made  marked  progress. 

'  The  comparative  freedom  of  the  Jewish  race  from  cancer  is  quite  remarkable. 
Why  this  should  be,  the  author  is  unable  to  explain  any  more  than  he  can  the 
liability  of  the  negress  to  fibroid  rather  than  ovarian  tumors. 


SA RCOMA .  —  CORRODING    UL CER.  3 1 1 

Subjective  symptoms  are  almost  always  wanting  in  the 
earlier  stages  ;  and  the  patient  does  not  apply  for  relief 
till  there  has  been  a  hemorrhage  from  some  compara- 
tively slight  cause,  such  as  coition.  This  has  been  pre- 
ceded usually  by  an  acrid,  profuse,  and  very  offensive 
watery  discharge,  sometimes  tinged  with  blood.  The 
latter  is  one  of  the  earliest  symptoms,  and  calls  for  a 
very  careful  examination  of  the  patient,  especially  if 
there  have  been  unusual  losses  of  blood. 

Sarcoma  grows  much  more  slowly  than  cancer,  but  its 
fatal  termination  is  equally  sure.  Its  symptoms  are  very 
similar  to  those  of  fibroid  tumors,  and  sometimes  the 
macroscopical  appearances  are  so  much  alike  that  only 
a  microscopic  examination  will  reveal  the  true  character 
of  the  growth.  Many  authorities  speak  of  a  hard 
sarcoma  as  a  recurrent  fibroid.  Fibroid  tumors  very 
rarely  become  the  seat  of  sarcomatous  degeneration. 
This  disease  is  almost  invariably  situated  at  or  near  the 
fundus,  and  does  not  tend  to  infiltrate  the  lymphatics 
and  neighboring  structures  as  does  carcinoma.  It  does 
not  always  occur  in  the  shape  of  a  well-defined  tumor 
simulating  a  fibroid,  but  quite  as  often  as  a  diffuse  in- 
filtration of  the  mucous  membrane  forming  soft  granu- 
lar masses,  or  knotty  villous  projections  growing  toward 
the  uterine  cavity  and  down  to  the  internal  os.  If  it 
originates  in  the  muscle  of  the  uterus,  it  may  be  seen 
in  the  shape  of  scattered  nodules  which  penetrate  the 
veins,  and  which  are  carried  to  adjacent  organs  or  even 
to  remote  parts  of  the  system.  The  chief  points  in 
making  a  differential  diagnosis  from  a  fibroid  tumor  are 
given  in  the  table  at  the  end  of  the  description  of 
carcinoma  (p.  315). 

Corroding  Ulcer  is  a  very  rare  affection,  and,  in  the 
great  majority  of  cases,  occurs  toward  the  close  of  the  cli- 
macteric.    It  is  found  extending:  from  the  cervix  to  the 


312    MALIGNANT  DISEASE  OF  SEXUAL  ORGANS. 

vagina,  and  is  probably  a  form  of  epithelioma,  though  its 
progress  appears  to  be  slower.  As  it  develops,  a  vesico- 
or  recto-vaginal  fistula  may  form,  and  all  the  subjective 
signs  of  cancerous  infection  of  the  system  be  present. 

Cancer.  —  Epithelioma  is  by  far  the  most  common 
form,  while  the  others  are  very  rare,  scirrhus  especially 
so.  Epithelial  cancer  is  almost  invariably  an  affection 
of  the  cervix  uteri,  from  which  it  may  spread  up  into 
the  body  of  the  uterus  or  down  on  the  vagina.  Medul- 
lary cancer  almost  always  attacks  the  uterine  cavity 
above  the  cervix. 

TJie  Etiology  of  this  dread  disease  is  not  well  under- 
stood, though  there  are  some  well-known  predisposing 
causes.  Like  all  forms  of  malignant  disease,  cancer 
develops  most  frequently  at  or  near  the  climacteric. 
Heredity  and  frequent  parturition  play  an  important  part. 
The  black  race  is  less  subject  to  it  than  the  white.  Of 
late  years  great  importance  has  been  attached  to  lacera- 
tion of  the  cervix  as  a  predisposing  cause.  It  is  not 
difficult  to  see  how  the  constant  irritation  from  the  fric- 
tion of  the  abraded  surfaces  would  tend  to  develop  local 
disease,  especially  in  those  having  hereditary  tenden- 
cies. The  writer  believes  it  should  be  an  invariable 
rule  to  close  every  abraded  laceration  of  the  cervix  in 
cases  where  there  is  any  hereditary  taint. 

Symptoms.  —  There  are  none  characteristic  of  the  in- 
ception of  this  disease.  Considerable  progress  is  often 
made  before  the  patient  notices  any  thing  unusual. 
The  earliest  symptom  in  most  cases  is  a  watery,  excori- 
ating vaginal  discharge,  which  is  occasionally  bloody, 
and  in  a  short  time  becomes  offensive.  The  hemor- 
rhage soon  increases,  and  is  easily  caused  by  coition  or 
the  careless  use  of  the  vaginal  douche.  There  is  also  a 
varying  amount  of  pelvic  pain  on  moving  about.  By 
this  time  there  is  a  cauliflower-like  growth  projecting 


EPITHELIOMA .  3  1 3 

into  the  vagina  from  the  cervix,  and  extending  up  a 
little  into  the  uterus.  Nature  apparently  tries  to  pre- 
vent systemic  infection  by  occlusion  of  the  lymphatics, 
which  become  engorged,  and  the  throwing-out  of  an 
exudation  in  the  cellular  tissue,  i.e.,  cellulitis,  in  which 
the  uterus  is  more  or  less  fixed  at  an  early  stage  of  the 
disease.  As  molecular  death  of  the  tissues  advances, 
there  is  increased  hemorrhage  from  excoriation  or 
sloughing  of  the  blood-vessels,  and  a  dark,  grumous,  or 
gruel-like,  vaginal  discharge,  of  an  extremely  offensive 
odor.  The  sallow  cancerous  cachexia  is  developed,  and 
septic  symptoms  gradually  appear  later  as  the  patient 
fails  in  strength  and  becomes  exhausted  by  hemorrhage 
and  by  pain.  The  latter  is  not  complained  of,  as  a  rule, 
till  the  disease  is  well  advanced  with  a  large  amount 
of  exudation  surrounding  the  uterus.  Death  generally 
takes  place  in  sixteen  or  eighteen  months  from  the 
beginning  of  the  disease,  except  where  life  may  be 
prolonged  by  treatment. 

The  Diagnosis  is  not  difficult  if  the  disease  has  made 
any  advance.  Besides  the  foregoing  symptoms,  the 
friable  cauliflower-like  growth  attached  to  the  cervix,  its 
bleeding  on  the  slightest  touch,  and  the  fixation  of  the 
uterus,  are  quite  enough  for  a  diagnosis.  Whenever 
malignant  disease  is  suspected,  the  vaginal  examination 
must  be  conducted  with  the  greatest  care,  lest  the  deli- 
cate and  friable  walls  of  the  blood-vessels  be  injured,  and 
profuse  hemorrhage  result.  By  gently  passing  the  fin- 
ger well  back  along  the  recto-vaginal  wall,  the  cervix 
can  be  felt,  and  the  surface  of  the  growth  touched  with- 
out injury. 

Epithelioma  is  the  only  growth  having  a  rough  friable 
surface  ;  excepting  the  stony  hardness  of  scirrhus,  all 
others  are  softer,  and  do  not  have  the  crumbling  sensa- 
tion to  the  touch  of  epithelioma. 


314    MALIGNANT  DISEASE  OF  SEXUAL  ORGANS. 


The  odor  left  on  the  examining  hand  is  extremely 
offensive,  and  difficult  to  remove.  The  writer  has  found 
Piatt's  chlorides,  full  strength  (which  is  immediately 
washed  off),  very  useful  for  this  purpose.  An  excellent 
authority  recommends  a  solution  of  thymol,  prepared  in 
the  following  way  :  Heat  three  drachms  of  alcohol,  and 
dissolve  fifteen  grains  of  thymol  in  it ;  then  add  half  an 
ounce  of  glycerine  and  thirty-four  ounces  of  water. 

The  Diagnosis  of  Cancer  at  an  Early  Period,  before 
any  marked  symptoms,  growth,  or  ulceration  have 
appeared,  is  exceedingly  difficult,  a  problem  in  most 
cases  which  only  time  can  solve.  Laceration  and 
hyperplasia  of  the  cervix,  with  hypertrophy  of  connec- 
tive and  fibrous  tissues,  produce  a  sclerosis  very  closely 
resembling  cancerous  infiltration.  A  dark  red  or  yel- 
lowish red  nodule,  which  bleeds  very  easily  and  projects 
on  the  cervix,  is  always  of  a  suspicious  character. 
Their  differences  are  contrasted  in  the  following  table, 
which  will  serve  also  for  the  diagnosis  of  probable  cancer 
in  an  early  stage  of  development :  — 


Benign  Sclerosis. 

Does  not  change  in  a  few 
months. 


Uniform  throughout  the  cer- 
vix. 

The  fissured  lobes  of  the 
cervix  are  smooth,  or  a  little 
rough  from  the  enlarged  Na- 
bothian  glands. 

The  erosion  about  the  os,  if 
present,  is  of  a  bright  red 
color. 


Maligna7it  Sclerosis. 

Begins  to  change  in  a  short 
time.  Cervical  sclerosis  lasting 
twelve  months  without  chan- 
ging is  almost  certainly  benign. 

One  part  of  cervix  hard,  the 
rest  of  a  normal  consistency. 

One  lobe  larger  than  the  oth- 
ers, with  a  nodulated  surface, 
or  there  is  a  dark  red  nodule 
which  bleeds  very  easily. 

The  mucous  membrane  on 
the  summit  of  the  nodules  may 
be  a  little  eroded,  and  has  a 
violet  or  livid  blue  color. 


DIFFERENTIAL   DIAGNOSIS. 


315 


Benign  Sclerosis. 


Malignant  Sclerosis. 

Granulations  exuberant,  and 
grow  rapidly. 

Is  not  expanded  by  a  sponge 
tent.' 

Is  soon  followed  by  offensive 
watery  or  bloody  discharges. 


If  granulations  appear  about 
the  OS,  they  grow  slowly. 

The  hardened  tissue  is  ex- 
panded by  a  sponge  tent. 

Is  not  liable  a  few  months 
after  its  discovery  to  be  fol- 
lowed by  watery  or  bloody 
discharges. 

Section  of  a  minute  piece 
under  the  microscope  shows 
an  excess  of  connective  and 
fibrous  tissue. 

Ca7icer  of  the  External  Genitals  does  not  differ  from 
its  general  characteristics  in  other  parts  of  the  body.  It 
usually  takes  the  form  of  the  corroding  ulcer  extending 
from  the  vagina,  or  of  an  epithelioma. 

All  forms  of  malignant  disease  end  fatally,  and  with 
similar  symptoms,  but  differ  widely  in  their  duration. 
The  following  table  may  be  useful  in  distinguishing 
them  from  uterine  fibroids,  and  from  one  another :  — 


Sections  show  nests  of  round 
or  epithelial  cells  in  stroma  of 
connective  tissue. 


uterine  Fibroids. 

Sarcoma. 

Corroding  Ulcer. 

Cancer. 

Comparatively 

Very  rare. 

Very  rare. 

Epithelioma    com- 

common. 

mon  ;     other    forms 
very  rare. 

Grows  slowly. 

Slowly,  but  more  rap- 
idly than  fibroids. 

Slowly. 

Most  rapidly  of  all. 

Very  hard. 

A  little  softer  than  a 

No   tumor,   but 

Soft    and    friable. 

fibroid. 

loss  of  substance 

excepting    the    scir- 

from    the    begin- 

rhous, which  is  very 

ning. 

hard. 

Most  common  on 

Scarcely  ever  seen  ex- 

Is on  the  cervix 

Is    almost    invari- 

the   posterior    wall, 

cept  at  or  near  the  fundus 

and  vaginal  walls. 

ably   in    the   cervix. 

but  not  limited  to  any 

uteri.      On  dilating  cer- 

and    scarcely     ever 

part   of    the   uterus. 

vix,  the  tumor  is  found 

found    primarily    in 

On    dilating    cervix, 

rounded,  and  a  little  soft. 

the  fundus  uteri. 

the   tumor  is   found 

more   often   small,   soft. 

hard  and  firm. 

and  granular. 

'  Spiegelberg's  test,  see  page  49. 


3l6    MALIGNANT  DISEASE  OF  SEXUAL  ORGANS. 


uterine  Fibroids. 

Sarcoma. 

Corroding  Ulcer. 

Cancer. 

Hemorrhage 

There  is  hemorrhage. 

Hemorrhage    is 

Very  offensive 

marked,  and  predom- 

but   watery    discharges 

a  marked    symp- 

ichorous, watery,  or 

inates  over  the  watery 

like   washings    of   meat 

tom. 

grumous  discharges. 

discharges. 

predominate.      They  do 

and  hemorrhage  more 

not  become  offensive  so 

or  less  profuse. 

early  in  this  disease  as  in 

cancer. 

Lymphatics      are 

Invasion  of   the   lym- 

Invasion is  very 

Invasion     is    very 

not  invaded. 

phatics   does   not  occur 

late,  and  no  infil- 

early. 

till  quite  late  in  the  dis- 

tration    in      the 

ease. 

neighboring    tis- 
sues. 

Uterus  movable  if 

Uterus     movable     ex- 

Uterus movable 

Uterus  is  fixed  and 

not  prevented  by  ad- 

cept in  the  last  stage. 

except  in  the  very 

immovable   early    in 

hesions,   or   size    of 

last  stage. 

the  disease. 

tumor. 

Does     not     recur 

Recurs. 

Recurs. 

Recurs. 

after  removal. 

As  the  encephaloid  and  colloid  varieties  of  cancer 
attack  the  ovaries,  and  scarcely  ever  the  uterus,  the 
reader  is  referred  to  the  chapter  on  ovarian  tumors  for 
a  description  of  them. 

The  Treatment  may  be  radical  or  palliative  ;  the  former 
when  all  the  diseased  tissue  can  be  safely  removed  ;  the 
latter  when  surgical  interference  is  impracticable.  If 
the  patient  is  strong  enough  for  an  operation,  it  should 
be  done  witho>ut  delay. 

Many  distinguished  surgeons  think  the  axillary  glands 
should  be  removed  in  every  case  of  mammary  cancer 
which  is  operated  on ;  otherwise,  the  operation  fails  in 
its  object,  and  the  cancer  is  sure  to  return  in  the  axilla 
at  an  early  period.  Should  experience  prove  that  the 
neighboring  lymphatic  glands  must  always  be  removed 
to  insure  a  new  lease  of  life  to  the  patient,  it  will  greatly 
limit  operating  for  uterine  cancer,  as  here  the  lymphatics 
are  involved  at  a  very  early  stage,  and  all  of  them  can- 
not be  removed. 


THE    TREATMENT  OF  CANCER.  317 

At  present,  experience  shows  that  early  removal  of 
all  the  diseased  tissue  prolongs  life,  while,  if  it  is  only 
partially  done,  the  remainder  of  the  cancerous  tissue 
grows  much  more  rapidly  than  if  left  alone.  Even  in 
the  latter  case  an  operation  has  been  thought  beneficial 
by  some,  as  there  would  be  less  sloughing  of  the  dis- 
eased mass,  and  less  danger  of  septicaemia  and  hemor- 
rhage. Experienced  operators,  however,  seldom  inter- 
fere with  the  intention  of  performing  an  incomplete 
operation.  After  the  removal  of  a  malignant  growth, 
the  patient  should  not  fail  to  report  every  month  or 
two  for  a  careful  examination,  and  if  the  least  nodule 
is  found  indicating  a  return,  it  should  be  removed  at 
once. 

The  practical  questions  for  a  physician  are  :  Is  the 
operation  feasible,  and  likely  to  benefit  the  patient,  i.e., 
the  limit  to  radical  treatment  ;  and,  second,  what  opera- 
tion to  select.  It  maybe  laid  down  as  a  rule,  that  where 
there  is  invasion  of  the  tissues  outside  of  the  uterus 
or  vagina,  or  secondary  deposits  elsewhere,  an  operation 
should  never  be  undertaken.  It  is  needless  to  add  that 
the  patient's  health  must  be  fairly  good,  as  there  is  often 
profuse  hemorrhage  during  the  operation. 

For  sarcoma  especially,  and  also  cancer  of  the  body 
of  the  uterus,  which  cannot  be  removed  with  certainty 
by  other  means,  extirpation  of  the  uterus  offers  the 
most  hope,  though  it  is  attended  by  a  high  rate  of 
mortality.'  Freund's  method  of  operating  by  opening 
the  abdominal  cavity,  and  ligating  the  lower  portions  of 
the  broad  ligaments  through  the  vagina,  is  exceedingly 
difficult  to  perform,  and  much  more  dangerous  ^  than 

'  For  a  history  and  description  of  tVie  methods  of  hysterectomy  up  to  1881,  the 
reader  is  referred  to  essays  by  Dr.  J.  Mikulicz,  in  the  Wien.  Med.  Wochenschrift , 
Nov.  20,  27,  Dec.  25,  1880  ;  Jan.  i,  8,  22,  Feb.  5,  12,  19,  26,  1881. 

^  B.  S.  Schultze,  Uber  Tntalextirpation  des  carcinomatosen  Uterus,  Deutsche 
Med.  Zeitung,  1886,  Nos.  2-4. 


3l8    MALIGNANT  DISEASE  OF  SEXUAL  ORGANS. 

extirpation  of  the  uterus  through  the  vagina  without 
opening  the  abdominal  wall.'  It  is  essential  for  the 
uterus  to  have  a  certain  amount  of  mobility  for  the  per- 
formance of  the  latter  operation. 

The  operation  of  vaginal  extirpation  of  the  uterus 
has  been  ably  discussed  by  Drs.  Martin  and  Jackson  ;- 
the  former  reporting  three  hundred  and  eleven  cases, 
with  a  mortality  of  only  15.1  per  cent.  This  is  less 
than  the  mortality  of  amputation  of  the  cancerous 
breast,  which  was  15.6  per  cent  in  seven  hundred  and 
seventy-eight  cases  reported  by  Kiister.  Dr.  Jackson, 
who  opposes  this  operation,  truly  says  that  the  mortality 
of  a  series  of  cases  operated  on  by  expert  surgeons  is 
not  a  correct  indication  of  the  mortality  among  those 
under  the  care  of  less  experienced  operators.  Dr.  Post  ^ 
compiled  the  statistics  of  three  hundred  and  forty-one 


'  Hegar  and  Kaltenbach,  Operative  Gynakologie,  1886.  See  also  Cyclopaedia 
of  Obstetrics  and  Gynaecology,  vol.  vii.  pp.  17,  22. 

'  Dr.  Hofmeyer  states  that  in  Schroeder's  clinic  at  Berlin,  there  have  been 
twenty-four  cases  of  total  vaginal  extirpation  of  the  uterus  without  a  single  death, 
and  expresses  his  opinion  that  in  malignant  diseases  of  the  uterus  removal  of  the 
entire  organ  is  more  correct  than  amputation  of  the  body  on\y.-- American 
Journal  of  Obstetrics,  October,  p.  1042,  1886. 

"  Dr.  Leopold  of  Dresden  has  removed  the  cancerous  uterus  per  vaginavi 
thirty-eight  times,  with  only  two  deaths.  —  American  Jour^ial  of  Obstetrics,  p.  918, 
September,  1886. 

Since  then  he  has  reported  forty-eight  cases  of  total  extirpation  of  the  uterus 
for  carcinoma,  procidentia,  and  severe  neuroses,  with  only  three  fatal  cases,  two  of 
which  were  from  sepsis.  This  gives  him  the  low  mortality  of  6.2  per  cent  for  this 
operation.  69.2  per  cent  have  remained  free  from  a  return  for  one  to  three  and  a 
quarter  years.  The  earlier  the  operation  is  performed,  the  longer  the  period  before 
the  return  "of  the  disease.  —  Leopold:  48  Totalextirpationen  des  Uterus  wegen 
Carcinom,  Totalprolafs,  iind  schwerer  Ncurosen,  Archiv  fiir  Gynakologie, 
Bd.  XXX.  Hft.  3. 

2  Transactions  of  the  Ninth  International  Medical  Congress,  Gynaecological 
Section,  1887.  A  good  report  of  this,  with  the  papers  of  Drs.  Jackson  and  Mar- 
tin, a  translation  of  Martin's  method  of  vaginal  extirpation  of  the  uterus  from  his 
Handbuch  der  Frauenkrankheiten,  1887,  and  other  interesting  information  con- 
cerning cancer  of  the  uterus,  will  be  found  in  the  Annals  of  Gynaecology,  Novem- 
ber, 1887. 

3  Dr.  Sarah  E.  Post,  American  Journal  of  the  Medical  Sciences,  January,  1885. 


VAGINAL    HYSTERECTOMY.  319 

cases,  in  which  the  mortality  was  27  per  cent.  Dr. 
A.  P.  Palmer  I  has  reported  a  list  of  sixty-six  cases  in 
which  twenty-three  died  within  a  week,  a  mortality  of 
34.8  per  cent.  These  are  the  results  of  thirty-three  oper- 
ators, many  of  whom  performed  the  operation  for  the 
first  and  only  time,  and  in  some  of  the  cases  the  opera- 
tion was  performed  as  a  last  resort,  so  that  this  mortality 
represents  the  other  extreme  to  Dr.  Martin's  report. 

Schauta  warmly  recommends  .vaginal  extirpation  of 
the  uterus  for  cancer,  and  well  says  that  the  success 
of  the  operation  lies  largely  in  the  hands  of  the  general 
practitioner,  as  many  cases  are  not  brought  to  the  ope- 
rator till  late  in  the  progress  of  the  disease.  The  earlier 
the  operation  is  performed,  the  more  likely  is  the  pa- 
tient to  recover  from  it,  and  the  longer  the  period  before 
the  disease  returns.  Every  dark-red  or  yellowish  nodule 
which  bleeds  very  easily,  and  projects  from  an  erosion 
on  the  cervix,  should  be  excised.  Fritsch^'  has  reported 
sixty  total  extirpations  of  the  uterus  with  seven  deaths. 
His  method  differs  somewhat  from  that  of  Martin,  and 
is  similar  to  that  described  by  Greig  Smith. ^ 

Prognosis.  — As  to  recurrence  of  the  disease,  the  bal- 
ance of  testimony  from  the  most  experienced  operators 
points  to  vaginal  extirpation  of  the  uterus  at  an  early 
stage  as  the  operation  followed  by  the  longest  immunity 
from  the  disease.  If  the  patient  has  no  return  of  the 
disease  at  the  end  of  a  year  from  the  operation,  it  is 
possible  that  the  cancer  will  not  recur ;  if  she  remains 
free  from  it  for  two  years,  it  may  be  stated  in  general 
terms  that  the  chances  of  non-recurrence  are  nearly 
even  ;  and  if  she  remains  free  for  four  years,  the  dis- 
ease is  not  likely  to  return. 

'  New  Yoik  Medical  Journal,  July  9  and  16,  18S7. 

^  Archiv  fiir  Gynakologie,  Bd.  xxix.  Hft.  3. 

3    Abdominal  Surgery,  Vaginal  Hysterectomy,  p.  185,  1887. 


320    MALIGNANT  DISEASE  OF  SEXUAL  ORGANS. 

For  epithelioma  of  the  cervix,  or  corroding  ulcer,  the 
methods  of  Sims,'  Schroeder,-  or  Baker,^  aided  by  the 
thermo-cautery  if  necessary,  are  the  most  efficient. 

Palliative  Treatment  consists  in  relieving  pain,  con- 
trolling hemorrhage,  and  neutralizing  the  offensive  odor. 
When  remedies  fail  in  the  former,  opium  in  some  form 
must  be  used.  An  application  of  chloral  hydrate,  one 
drachm  to  an  ounce  of  glycerine,  or  stronger  if  neces- 
sary, is  warmly  praised  for  this  purpose.  Iodoform  in 
powder  has  disinfecting  and  slight  narcotic  properties  ; 
or,  both  iodoform  and  chloral  hydrate  may  be  combined 
in  the  form  of  a  vaginal  suppository  containing  ten 
grains  of  each.  When  these  will  serve  the  purpose  of 
allaying  the  pain,  opium  should  not  be  employed,  as  the 
latter  causes  more  or  less  derangement  of  the  system. 

It  is  a  good  plan  for  the  patient  to  keep  a  saturated 
solution  of  alum  at  hand  to  use  as  an  injection  in 
case  of  unexpected  hemorrhage.  The  application  of 
Churchill's  tincture  of  iodine  to  the  entire  surface  of 
the  cancer  seems  to  check  the  progress  of  the  disease 
to  a  limited  extent,  and  also  to  control  the  loss  of  blood. 
Bleeding  spots  may  be  touched  with  diluted  perchloride 
of  iron,  or  the  dry  sub-sulphate  of  iron  can  be  locally 
applied.  It  is  well  to  bear  this  in  mind  in  case  of 
unexpected  and  severe  hemorrhage  from  a  vaginal 
examination. 

Fritsch  ■*  highly  recommends  packing  the  vagina  with 
a  strip  of  iodoform  gauze  for  carcinoma  of  the  uterus. 
The  iodoform  is  combined  with  an  equal  amount  of 
tannin  on   account  of  its  astringent  effect,  and  for  the 

'  The  Treatment  of  Epithelioma  of  the  Cervix  Uteri. —  Americaji  Journal  of 
Obstetrics,  vol.  xii.  No.  3,  July,  1879. 

^  Krankheiten  der  weibl.  Gesclilechtsorgane,  1881,  p.  28S.  Compare  ed.  ot 
18S7. 

3  American  Journal  of  Obstetrics,  April,  1882,  and  February,  1886,  p.  184. 

■♦  Volkmann's  Sammlung,  No.  288. 


THERAPEUTICS   OE  MALIGNANT  DISEASE.     32 1 

purpose  of  disguising  the  odor  of  the  iodoform.  This 
is  also  used  for  a  dressing  after  the  palliative  surgical 
treatment.  Here  the  raw  surface  is  covered  with  iodo- 
form and  tannin  in  powder,  and  the  gauze  packed 
against  it.  He  claims  the  carcinomatous  odor  is  en- 
tirely controlled  by  this  treatment. 

The  offensive  odor  can  also  be  corrected  by  douches 
of  from  two  to  five  per  cent  solutions  of  carbolic  acid, 
creosote,  permanganate  of  potash,  or  thymol.  The  noz- 
zle of  the  syringe  must  be  introduced,  and  the  water 
injected  very  carefully  lest  hemorrhage  be  caused.  The 
tip  can  be  shielded  by  a  piece  of  rubber  tubing  drawn 
over  it,  with  holes  in  the  sides,  and  projecting  about  an 
inch  from  the  end. 

The  Diet  must  be  generous,  and  the  system  well 
nourished  so  as  to  counteract  as  long  as  possible  the 
poisonous  influence  of  the  cancer. 

The  Medical  Treatment  has  but  little  encouragement 
to  offer,  except  as  it  can  relieve  pain,  and  check  the 
progress  of  the  disease,  or  systemic  infection.  The 
physician  has  yet  to  discover  the  remedy  which  has 
any  decided  curative  effect  on  cancer.  The  discovery 
of  the  bacillus  of  cancer,  while  of  great  interest,  is  not 
any  more  likely  to  lead  to  a  cure  of  this  disease  than 
the  discovery  of  the  tubercle  bacillus  has  to  the  cure 
of  pulmonary  phthisis. 

THERAPEUTICS. 

I  Arsenicum  has  been  the  favorite  remedy  for  cancer,  some 
physicians  preferring  Fowler's  solution,  but  more,  the  iodide  of 
arsenic.  It  corresponds  best  to  the  later  stages  of  the  disease 
when  the  cachexia  begins  to  develop.  Great  exhaustion  ;  rest- 
lessness ;  much  thirst ;  hemorrhage  with  lancinating  burning 
pains  in  pelvis ;  acrid,  watery,  corrosive  leucorrhoea,  sometimes 
offensive. 


322    MALIGNANT  DISEASE  OF  SEXUAL  ORGANS. 

Calcarea  carb.  This  would  seem  a  possible  remedy  for 
cancer,  judging  by  the  two  cases  cured  by  it  in  the  shape  of 
powdered  oyster-shells,  which  were  reported  by  Dr.  Peter 
Hood,  in  the  "Lancet"  for  1868.  His  observations  were 
authenticated  by  Mr.  Spencer  Wells. 

Graphites  was  recommended  by  Wahle,  but  has  not  met 
the  expectations  of  some  other  physicians.  It  seems  best 
adapted  to  epithelioma ;  menses  only  once  in  six  weeks,  the 
flow  being  black,  clotted,  and  offensive  ;  constipation. 

I  Creosote.'  Epithelioma,  much  burning  and  pain  in  the 
pelvis.  The  discharges  are  acrid,  excoriating,  and  offensive ; 
pruritus  vulvae ;  external  os  open.  Coition  painful,  accompa- 
nied by  burning,  and  followed  by  a  bloody  discharge.  Menses 
too  early,  too  profuse,  and  protracted ;  flow  dark,  lumpy,  and 
offensive. 

Lachesis  is  more  useful  at  the  climacteric  period.  Dr. 
Ludlam  mentions  it  for  a  tendency  to  passive  hemorrhages, 
alternating  with  a  profuse  discharge  of  blood,  sharp  lancinating 
pains  in  the  pelvis. 

Nitric  acid.  Epithelioma  of  the  cervix.  Irregular  men- 
struation, with  intercurrent,  profuse,  brown,  offensive  discharges. 
Hemorrhoids  with  burning,  sticking  pains  in  the  rectum.  Baehr 
states  that  this  drug  is  only  suitable  as  an  intercurrent  remedy 
at  the  commencement  of  the  disease,  and  is  of  no  use  when 
ichorous  dissolution  has  commenced. 

Tarrentula.  Dr.  Nunez  recommends  it  for  a  cancerous 
ulcer  of  the  os,  induration  of  the  neck  and  fundus  of  the 
uterus,  chronic  vaginitis  with  granulations.  It  would  therefore 
seem  to  be  especially  useful  for  corroding  ulcer. 

The  following  remedies  have  been  recommended  for 
cancer,  and  are  worthy  of  study  :  — 

Alveoloz,^  argentum  met.,  aurura,  carbo  an.,  carbo  veg., 
cedron,    coniinn,    cundurango  (?),    iodine,    juglans    cin., 

'  See  Kiickert's  Klinische  Erfahningen,  vol.  ii.  p.  353. 

^  Alveoloz.  The  fresh  juice  (jf  the  plant  is  applied  locally.  See  paper  by 
Dr.  I.  A.  Velloso,  British  Journal  of  Horn.,  p.  201,  1884. 


THERAPEUTICS  OF  MALIGNANT  DISEASE.    323 

ham./  hydrocot.  asiat./  Hydrastis,  lapis  alba/  phytolacca, 
platina/  sabina/  sang.^  (to  prevent  return  after  excision), 
secale,'  sepia,  silicea,  thuja^   (epithelioma)/ 

'  These  remedies  are  more  useful  to  control  the  loss  of  blood  than  for  any 
specific  influence  on  the  disease. 

2  Ruddock,  Text-book  Prac.  Med.  and  Surg.,  p.  453. 

3  Dr.  V.  Grauvogl  states  that  five  cases  of  uterine  cancer,  pronounced  to  be  such 
and  incurable  by  these  old-school  physicians,  were  completely  and  permanently 
cured  by  this  remedy.  It  must  be  used  before  the  tissues  break  down.  He  has 
never  seen  any  benefit  from  it  in  open  cancer. — Allgemeine  Horn.  Zeitung,  June 
15,  1874. 

*  Dr.  Schwabe  found  it  very  beneficial  in  a  case  of  cancroid,  though  recovery 
did  not  take  place.  —  Lehrbiuh  der  horn.  Therapie^  3d  ed.,  1S82,  vol.  ii.  p.  995. 


324      PELVIC  CELLULITIS  AND  PERITONITIS. 


CHAPTER    XXII. 

PELVIC  CELLULITIS  (PARAMETRITIS), '  PELVIC 
PERITONITIS  (PERIMETRITIS),  AND  PELVIC 
ABSCESS. 

THESE  diseases  are  the  most  common  of  those 
peculiar  to  women,  and  there  are  few  affections 
which  have  given  rise  to  so  much  dispute,  —  the  advo- 
cates of  one  almost  ignoring  the  existence  of  the  other. 
Unfortunately,  morbid  anatomy  has  not  been  able  to 
settle  definitely  the  disputed  question,  as  there  are 
comparatively  few  opportunities  for  necropsies  in  the 
various  stages  of  either  disease,  and  the  false  mem- 
branes of  pelvic  peritonitis  sometimes  so  closely  resem- 
ble the  peritoneum  as  to  cause  error  in  determining  the 
origin  of  the  disease  by  its  post-mortem  appearance. 

Theoretically,  they  are  separate  and  distinct  from 
each  other  ;  but  from  the  practical,  clinical  standpoint 
of  the  practitioner,  the  writer  believes  these  affections 
co-exist,  though  one  may  largely  predominate  over  the 
other  ;  just  as,  in  pneumonia,  the  lung  symptoms  are  the 
most  prominent,  though  in  all  marked  cases  the  pleura 
is  more  or  less  involved.     A  no  less  distinguished  writer 

'  Dr.  W.  A.  Freiind  has  given  a  very  thorough  description  of  chronic  atrophic 
parametritis  in  his  Gyndkologische  Klinik,  vol.  i.  p.  203,  piibHshed  by  Triibner 
in  Strasburg.  A  review  of  it  will  be  found  in  the  Centralblatt  fiir  Gynakologie, 
p.  447,  1S86.  It  is  characterized  by  chronic  inflammation  of  the  fascia,  and  apo- 
neurosis of  the  fatless  connective  tissue,  with  subsequent  contraction  as  in  cirrhosis 
of  the  liver  ;  uterine  displacements,  etc.,  follow.  Pessaries  are  useless  in  this 
disease,  so  far  as  a  cure  is  concerned.  The  author  can  add  no  treatment  for  it 
differing  from  that  given  for  pelvic  cellulitis.  The  action  of  morphia  in  causing 
atrophy  of  the  female  genital  organs,  especially  of  the  ovaries,  suggests  a  possible 
remedy  for  it.  An  interesting  report  of  such  a  case,  by  Dr.  Levinstein,  can  be 
found  in  the  Centralblatt  fiir  Gynakologie,  No.  40,  p.  633,  Oct.  I,  1887. 


PELVIC  CELLULITIS.  325 

than  Dr.  Emmet  declares  his  inability  to  distinguish 
between  them,  and  employs  the  term  "cellulitis"  as  the 
most  common  pelvic  inflammation  of  the  non-puerperal 
state,  reserving-  "pelvic  peritonitis,"  not  for  a  distinct 
and  separate  lesion,  but  for  a  much  graver  complication 
of  the  cellulitis.  This  is  directly  contrary  to  the  views  of 
Drs.  Schroeder,  Thomas,  and  others,  and  the  last  con- 
dition applies  to  what  the  latter  would  call  pelvic  peri- 
tonitis in  the  great  majority  of  cases. 

These  subjects  will  be  treated,  therefore,  not  as  abso 
lutely  distinct  from  each  other,  but  as  co-existing  to  a 
certain  extent,  the  one  or  the  other  predominating  suffi- 
ciently to  warrant  the  corresponding  name,  while  in 
rare  cases  both  may  be  present  to  an  alarming  extent, 
and  seriously  threaten  or  destroy  the  life  of  the  patient. 

Pelvic  Celliditis,  or  parametritis,  as  Professor  Vir- 
chow  styled  it  in  contra-distinction  to  perimetritis  for 
pelvic  peritonitis,  means  a  local  or  general  inflammation 
of  the  areolar  tissue  of  the  pelvis,  without  including 
periproctitis,  psoas,  or  iliac  abscess. 

It  is  often  associated  with  the  puerperal  state,  and  is 
excited  by  exposure  to  cold,  traumatism,  and  rarely 
extension  of  inflammation  from  neighboring  structures. 
A  similar  condition  is  seen  in  the  cellulitis  appearing 
early  in  the  development  of  malignant  disease  of  the 
uterus,  and  fixing  that  organ.  The  great  majority  of 
cases  follow  abortion,  or  labor  at  full  term,  and,  accord^ 
ing  to  Professor  Schroeder,  are  due  to  septic  infection. 
The  writer  has  seen  a  number  of  cases  diagnosed  as 
uncomplicated  puerperal  fever,  without  a  suspicion  that 
an  extensive  cellulitis  was  present. 

As  causes  of  traumatism,  may  be  cited,  coition  too 
soon  after  confinement  (a  physician  neglects  his  whole 
duty  if  he  fails  to  warn  his  patients  against  sexual  in- 
tercourse before  three  months  after  delivery) ;  surgical 


326      PELVIC  CELLULITIS  AND  PERITONITIS. 

operations,  especially  on  the  cervix  ;  ill-fitting  pessa- 
ries ;  and  harsh  applications  or  examinations  when  the 
uterus  or  neighboring  tissues  are  unduly  sensitive.  It 
is  most  likely  to  follow  surgical  operations  when  the 
patient  is  in  an  enfeebled  condition,  when  chronic  cellu- 
litis is  already  present,  and  from  septic  infection. 

In  very  exceptional  cases,  all  the  cellular  tissue  about 
the  uterus  is  involved  in  the  inflammation  ;  but  as  a 
rule  it  is  limited  to  one  side  of  the  uterus  or  a  broad 
ligament,  and  most  often  in  the  left  side  of  the  pelvis. 
Not  infrequently  the  exudation  extends  up  and  out  of 
the  pelvis,  so  that  it  can  be  palpated  externally,  espe- 
cially in  puerperal  cases. 

The  Clinical  History  of  pelvic  cellulitis  comprises 
three  stages:  congestion,  exudation,  and  resolution,  or, 
less  often,  suppuration.  In  nearly  all  cases  there  are 
marked  symptoms  in  the  beginning  of  the  disease, 
which  is  ushered  in  with  a  chill  followed  by  fever,  and  a 
variable  amount  of  pain  in  proportion  to  the  extent  to 
which  the  peritoneum  is  involved. 

On  examination,  the  vagina  is  hot  and  sensitive,  par- 
ticularly at  some  spot,  and  an  expert  may  be  able  to 
distinguish  a  localized  puffiness  or  oedematous  condition 
of  the  tissues.  This  stage  is  succeeded  in  a  few  hours 
by  the  stage  of  exudation  or  effusion  at  the  site  of  the ' 
inflammation.  The  symptoms  of  fever  continue,  the 
'temperature  being  a  little  higher  toward  evening  ; 
dysuria  and  menorrhagia  or  metrorrhagia  are  not  un- 
common. A  thin  leucorrhoeal  discharge  from  the 
uterus  may  give  rise  to  the  diagnosis  of  endometritis; 
but  this  is  secondary  to  the  cellulitis,  and  any  applica- 
tion to  the  endometrium  might  be  followed  by  a  fatal 
increase  of  the  inflammation.  There  is  more  or  less 
pelvic  pain  from  the  pressure  of  the  exudation  on  the 
nerves,  and  the  drawn-up  adducted  position  of  the  thigh 


CLTNICAL   HISTORY  OF  CELLULITIS.         327 

is  characteristic.  Not  infrequently,  the  patient  limps 
on  the  side  corresponding  to  the  exudation.  Induration 
in  the  inflamed  areolar  tissue  progresses  in  proportion 
to  the  amount  of  the  effusion  in  it  of  the  liquor  san- 
guinis. It  is  apparent,  therefore,  that  while  the  tumor 
thus  formed  will  vary  in  location,  size,  and  consistence, 
it  will  have  a  peculiar  feature,  that  of  immobility,  —  an 
important  fact  in  differential  diagnosis. 

The  tumor  is  most  often  found  near  the  angle  of  a 
lacerated  cervix,  or  in  the  left  broad  ligament  ;  from 
here  it  may  extend  up  and  out  of  the  true  pelvis,  so  as 
to  be  easily  felt  externally.  This  is  especially  true  of 
puerperal  cellulitis.  On  examination,  its  consistence 
will  be  found  to  vary  at  different  periods  of  the  second 
stage.  In  the  beginning,  only  a  diffuse  resistance  is 
felt,  without  sharply  defined  borders.  In  exceptional 
cases,  the  uterus  may  rest  in  a  bed  of  cellulitic  exuda- 
tion ;  here,  the  pelvic  peritonitis  is  an  important  com- 
plication, and,  as  a  rule,  the  predominant  disease.  In  a 
short  time,  the  exudation  grows  harder,  with  well-defined 
borders,  till  it  seems  as  if  molten  lead  had  been  run  into 
the  tissues  and  hardened  in  them.  While  it  is  quite 
sensitive  in  the  beginning  in  proportion  to  the  extent 
of  inflammation  of  the  peritoneum  accompanying  the 
cellulitis,  it  gradually  diminishes  till  it  can  be  freely 
handled  without  causing  much  pain. 

In  the  third  stage  of  absorption,  the  former  symp- 
toms of  fever  and  local  inflammation  gradually  subside; 
the  tumor  slowly  dimishes  in  size  and  sensitiveness,  but 
becomes  harder.  The  absorption  of  large  exudations 
is  usually  accompanied  by  a  variable  amount  of  hectic 
fever.  In  some  cases  tjie  tumor  remains  stationary  for 
an  indefinite  period. 

Fortunately,  most  cases  undergo  absorption,  and  few 
suppuration.     If  the  latter  takes  place,  the  symptoms  of 


328      PELVIC  CELLULITIS  AND  PERITONITIS. 

fever  and  inflammation  do  not  subside,  the  tumor  remains 
soft  and  very  sensitive ;  the  temperature  increases,  being 
higher  at  night  than  in  the  morning.  Chills  may  attend 
the  formation  of  pus,  but  do  not  always.  The  further 
consideration  of  suppuration  will  be  found  under  the  head 
of  Pelvic  Abscess,  in  the  chapter  on  Pelvic  Peritonitis. 

It  is  not  to  be  supposed  that  all  cases  of  cellulitis 
have  marked  symptoms,  and  run  a  perfectly  typical 
course  as  described  above.  There  are  some  exceptions 
to  the  rule.  A  woman  does  not  seem  to  do  well  for 
some  weeks  after  confinement.  She  suffers  no  acute 
pain,  but  has  a  sense  of  soreness,  loss  of  appetite,  some 
fever,  is  weak  and  listless,  and  a  careful  examination 
often  reveals  extensive  cellulitis. 

The  Diagnosis  is  easy  in  nearly  all  cases  when  the 
exudation  is  large  ;  but  if  very  small,  it  is  more  difficult. 
Though  the  symptoms  may  point  to  the  disease,  an 
examination  is  necessary  for  a  positive  diagnosis,  and  to 
determine  the  extent  of  the  affection.  The  patient  must 
occupy  the  dorsal  position,  with  all  the  clothing  loosened, 
and  the  thighs  drawn  up  to  relax  the  abdominal  muscles. 
The  physician  then  carefully  palpates  with  the  palmar 
surfaces  of  the  fingers  over  the  hypogastric  region  and 
sides  of  the  pelvis,  to  ascertain  if  the  exudation  has  ex- 
tended up  out  of  the  true  pelvis.  He  next  thoroughly 
anoints  the  forefinger,  and  gently  and  slowly  introduces 
it  along  the  posterior  wall  of  the  vagina,  taking  note  at 
the  same  time  of  the  heat  and  dryness  of  the  canal. 
The  cul-de-sac  of  Douglas  is  examined  with  a  very  gentle 
touch  ;  also  the  region  all  around  the  cervix  ;  and,  finally, 
the  broad  ligaments,  with  the  careful  help  of  the  other 
hand  outside  over  the  corresponding  regions.  If  there 
is  not  much  sensitiveness,  considerable  pressure  of  the 
opposed  fingers  may  be  necessary  to  distinguish  and  ac- 
curately map  out  a  small  exudation.     A  rectal  examina- 


DIFFERENTIAL   DIAGNOSIS,   ETC.  329 

tion  will  often  disclose  an  exudation  in  the  utero-sacral 
ligaments  which  would  otherwise  escape  notice. 

In  regard  to  a  differential  diagnosis  between  an  exuda- 
tion in  the  cellular  tissue  and  one  in  the  peritoneum,  it 
is  said  that  the  uterus  is  immovable,  and  often  con- 
nected with  the  cellulitic  tumor,  but  is  much  more  free 
and  movable  in  peritonitis;  in  cellulitis  the  exudation  is 
lower  in  the  pelvis  than  in  pelvic  peritonitis. 

The  character  of  the  cellulitic  tumor  has  been  de- 
scribed above.  When  it  is  very  large,  it  crowds  the 
uterus  one  side  or  out  of  place,  and  may  press  hard 
enough  upon  some  nerve  to  cause  severe  neuralgic  pain 
in  the  pelvis  or  leg.  With  the  stage  of  absorption,  the 
uterus  not  only  resumes  its  former  position,  but  with 
the  continued- contraction  of  the  tissues  is  also  perma- 
nently drawn  out  of  place.  Lateral  version  or  flexion  is 
the  most  common  form  of  displacement  from  this  cause  ; 
i.e.,  cellulitis  in  one  of  the  broad  ligaments.  Sterility 
sometimes  follows  from  destruction  of  the  Graafian  fol- 
licles or  ovaries  by  suppurative  action  or  atrophy,  also 
from  adhesions  binding  the  Fallopian  tubes  down,  and 
rendering  them  impervious.  Uterine  displacement  and 
sterility  are  far  more  frequently  the  result  of  peritonic 
complications.  Secondary  to  these  may  be  mentioned 
salpingitis,  amenorrhoea,  menorrhagia,  and  dysmenor- 
rhoea. 

The  Prognosis  depends  largely  on  the  violence  of  the 
symptoms  and  the  extent  of  the  exudation.  Life  is 
seldom  in  danger.  A  small  abscess  may  form,  break, 
and  heal  up  in  a  few  days,  or  the  effused  mass  become 
absorbed  in  a  fortnight ;  but  this  is  exceedingly  rare,  and 
no  amount  of  skill  will  always  predict  the  time  of 
recovery.  When  the  tumor  is  sharply  defined  and  not 
very  sensitive,  the  prospect  of  complete  cure  is  very 
good  if  the  patient  be  willing  to  follow  her  instructions 


330      PELVIC  CELLULITIS  AND   PERITONITIS. 

for  a  sufficient  length  of  time.  It  is  better  to  qualify 
the  prognosis  to  her,  and  state  that  if  she  recovers  in 
six  weeks  she  will  do  well,  though  sometimes  such 
cases  get  well  sooner. 

The  general  principles  of  local  treatment  are  so 
similar  to  those  of  pelvic  peritonitis,  they  will  be  con- 
sidered together.  The  reader  is  therefore  referred  to 
the  following  section,  both  for  treatment  and  the  differ- 
ential diagnosis  (pp.  340,  343). 

Pelvic  Peritonitis  (perimetritis)  is  very  common  in 
the  non-puerperal  state,  and  less  frequently  seen  after 
delivery  than  cellulitis,  which  is  rarely  independent  of 
delivery  or  traumatism.  In  other  words,  the  pelvic 
inflammation,  often  called  cellulitis,  is  really  of  peri- 
toneal origin.  It  is  a  local  peritonitis  ;  and  bearing  this 
in  mind  will  aid  in  studying  the  etiology  and  pathology, 
as  well  as  the  treatment.  The  causes  of  pelvic  peri- 
tonitis may  be  classified  as  follows  :  — 

f  Pelvic  cellulitis. 

Extension  of  in-  j  Endometritis, 

flammation         I  Salpingitis.  , 

I  Ovaritis. 


Escape  of  fluids 


'  Products  of  catarrhal  or  purulent  inflamma- 
tion (gonorrhoea)  from  the  Fallopian 
tubes. 

^"  °     ^     P     '1   Hemorrhage  into  peritoneal  cavity. 

toneal  cavity         r.      ^  c       ^ 

^       I   Rupture  of  cysts. 

1-  Intra-uterine  injections. 

r  Parturition  or  abortion. 

J   Surgical  operations. 
Traumatism  j  gj^^^  ^^  ^^^^^^ 

I  Excessive  venery. 
Sudden  suppression  of  the  menstrual  flow. 
Uterine  displacement. 
Ovarian  or  sub-peritoneal  tumors. 
The  presence  of  malignant  or  tubercular  disease. 


PELVIC  PERITONITIS.  33  I 

The  relation  of  most  of  these  causes  to  pelvic  peri- 
tonitis is  too  evident  to  need  further  explanation.  The 
effect  of  gonorrhoea  extending  successively  from  the 
vagina,  uterine  cavity,  and  through  the  Fallopian  tubes 
to  the  peritoneum,  is  seen  among  immoral  v^omen,  who 
are  especially  subject  to  this  form  of  peritonitis.  Some 
physicians  believe  that  a  woman  who  has  had  gonor- 
rhoea cannot  conceive.  The  condition  of  the  system, 
and  the  retrogressive  changes  following  delivery,  power- 
fully predispose  the  patient  to  either  peritonitis  or  cel- 
lulitis from  slight  causes,  and  make  her  susceptible  to 
septic  infection.  The  importance  of  the  lymphatic 
system  in  connection  with  these  diseases  has  not  re- 
ceived sufficient  attention.  When  the  lymphatics  be- 
come clogged,  as  in  malignant  disease,  tuberculosis,  or 
septic  infection,  inflammation  in  the  surrounding  tissue 
seems  pretty  sure  to  follow. 

The  irritation  caused  by  the  presence  of  a  tumor 
results  in  the  adhesions  which  are  so  common. 

Surgical  operations,  even  of  the  most  trivial  character, 
or,  indeed,  any  mechanical  interference  with  the  nterns, 
a  sound,  pessary,  etc.,  must  never  be  performed  or  used 
IV  hen  there  is  either  general  or  local  painful  sensitiveness 
of  the  pelvic  organs,  the  ovaries  excepted.  Furthermore, 
the  precautions  taken  in  operations  on  other  parts  of  the 
body  sho?dd  be  observed  more  rigidly,  if  possible,  in  those 
involving  the  generative  system. 

The  pathological  appearances  may  be  summed  up  in 
thickening  of  the  peritoneum  and  adhesions  to  the 
uterus,  ovaries,  intestines,  omentum,  etc.,  varying  from 
fine  delicate  threads  to  firm  bands  or  sheets  of  tissue, 
en  capsuling  serous  or  purulent  exudations. 

Like  its  neighbor,  pelvic  cellulitis,  pelvic  peritonitis 
may  develop  insidiously  or  with  marked  symptoms, 
which  is  the  rule  ;  may  run  an  acute  or  chronic  course ; 


332      PELVIC  CELLULITIS  AND  PERITONITIS. 

and,  for  convenience  of  description,  is  divided  into  tliree 
similar  stages,  —  congestion,  effusion,  and  resolution  or 
suppuration. 

The  Clinical  History  of  acute  pelvic  peritonitis  dur- 
ing the  first  stage  is  very  characteristic.  The  patient 
feels  chilly,  though  this  is  sometimes  absent  ;  then  fol- 
lows increase  of  pulse  and  temperature,  tenderness  over 
the  hypogastrium,  and  pain,  which  may  be  intense. 
There  may  even  be  tympanitic  distension  of  the  abdo- 
men and  vomiting.  The  peculiar  anxious,  drawn  ex- 
pression of  the  face  is  an  important  symptom. 

Though  these  are  the  more  common  phenomena 
marking  the  commencement  of  this  disease,  there  are 
two  other  forms,  as  in  general  peritonitis,  where  nearly 
all  of  them  may  be  wanting.  In  one,  the  characteristic 
expression  of  the  face  is  present;  the  patient  passes 
into  a  weak  or  collapsed  state  within  some  hours,  or 
two  or  three  days,  suffers  no  pain,  and  ,the  pulse  and 
temperature  are  not  in  proportion  to  each  other  or  the 
serious  condition  of  the  patient,  —  i.e.,  the  pulse  goes 
up,  while  the  temperature  remains  near  or  below  normal. 
Very  few  of  these  cases  recover.  The  other  form  may 
be  termed  chronic,  and  invades  the  pelvis  to  a  great 
extent,  without  other  symptoms  than  a  poor  appetite, 
perhaps  slight  fever,  painful  coition,  and  some  indefinite 
pain  or  soreness  in  the  uterine  region  after  unusual 
exercise.  The  chronic  form  results  from  the  presence  of 
malignant  or  tubercular  disease,  gonorrhceal  infection, 
displacements  of  the  uterus,  and  pelvic  tumors.  If  the 
patient  does  not  succumb  to  the  acute  form,  it  is  much 
more  likely  to  terminate  in  suppuration  than  if  it  de- 
velops more  slowly  and  insidiously. 

Most  of  the  symptoms  of  the  first  stage  are  con- 
tinued into  the  second,  that  of  effusion,  which  may 
consist    of   coagulable    lymph    on    the    surface   of    the 


CLINICAL  HISTORY  OF  PELVIC  PERITONITIS.     333 

membrane  in  mild  cases,  a  collection  of  serum,  or  it 
may  even  be  sero-purulent  in  severe  forms  of  a  septic 
origin.  The  effusion  usually  becomes  encapsuled  by 
adhesions  and  the  formation  of  false  membranes,  slowly 
shrinks,  and  hardens  as  the  vi^atery  portion  is  absorbed. 
It  may  form  a  localized  tumor  at  one  side  of  the  uterus, 
or  settle  in  the  cul-de-sac  of  Douglas,  and  rise  up  around 
the  uterus  ;  as  it  hardens,  the  entire  vault  of  the  vagina 
becomes  hard,  and  feels  as  if  plaster-of-Paris  had  been 
run  into  the  pelvis  and  hardened  there  and  all  about 
the  uterus,  which  is  fixed  by  it  in  severe  cases.  The 
disease  has  now  become  chronic  ;  the  fever,  tempera- 
ture, and  extreme  sensitiveness  abate,  but  the  patient 
complains  of  a  variable  amount  of  pelvic  pain  aggravated 
by  walking  and  unusual  exercise ;  dysuria  is  common 
when  the  utero-sacral  ligaments  are  involved,  and  the 
symptoms  are  often  worse  at  the  menstrual  periods. 

Excepting  by  the  previous  history  of  the  case,  it  is 
generally  impossible  to  distinguish  between  pelvic  cel- 
lulitis and  pelvic  peritonitis  in  the  second  stage  after 
the  acute  symptoms  have  subsided.  The  fact  that  eel-, 
lulitis  in  this  stage,  independent  of  traumatism  and  par- 
turition, has  scarcely  ever  been  found  at  an  autopsy  by 
any  observer,  and  that  the  cases  diagnosed  as  cellulitis 
have  proved  to  be  peritonitis,  make  it  highly  probable 
that  cellulitis  is  not  nearly  so  common  as  has  been 
supposed.  Besides,  the  long  duration,  and  the  suscep- 
tibility of  exacerbations'  from  exceedingly  slight  and 
apparently  unimportant  causes,  point  to  the  sensitive 
peritoneum  as  the  source  of  the  disease.  The  perito- 
neal exudation  is  less  likely  to  suppurate,  is  higher  in 
the  pelvis,  and,  as  a  rule,  allows  more  mobility  to  the 
uterus,  than  the  cellulitic  tumor. 

As  the   symptoms    slowly   disappear  with   the   third 
stage,  of   resolution,  the   patient's   general  health    im- 


334      PELVIC   CELLULITIS  AND   PERITONITIS. 

proves  in  proportion  ;  but  for  months  she  will  have  to 
guard  against  cold,  traumatism  in  any  form,  etc.,  or  the 
peritonitis  will  re-appear  in  all,  if  not  more  than,  its 
former  intensity. 

The  Diagjiosis  of  acute  cases  is  very  easy  when  the 
symptoms  are  marked,  or  in  the  second  stage  with  the 
pelvis  filled  with  exudation,  and  the  tissues  surrounding 
the  uterus  very  hard.  It  is  remarkable,  however,  how 
many  cases  of  small  exudations  are  overlooked,  par- 
ticularly when  situated  in  the  utero-sacral  ligaments  or 
on  the  posterior  upper  surface  of  the  broad  ligaments, 
which  are  common  sites  of  this  disease.  In  the  acute 
stage,  with  high  fever  and  extreme  local  sensitiveness, 
the  local  examination  with  finger  or  instruments  had 
better  be  deferred,  as  no  good  and  much  harm  may 
come  from  it.  When  the  more  severe  symptoms  have 
subsided,  a  careful  examination  is  necessary  to  confirm 
the  diagnosis,  and  adopt  proper  methods  of  treatment. 

In  nearly  all  cases  of  disease,  it  is  well  to  have  the 
patient  in  bed,  where  there  are  no  obstacles  to  a  thor- 
ough examination,  and  the  physician  can  freely  use  his 
hands  or  stethoscope  as  he  sees  fit.  Here,  too,  there 
must  be  no  obstacles.  The  clothing  should  be  freely 
loosened,  the  patient  lie  on  her  back,  with  the  thighs 
moderately  flexed  on  the  abdomen.  The  bi-manual 
method  must  be  carefully  employed  ;  for  gentleness,  not 
force,  and  the  power  of  concentrating  the  attention  on 
the  touch  of  the  examining  finger,  are  requisites  for  a 
skilful  examiner.  The  ability  to  detect  small  adhesions 
which  only  partially  fix  the  uterus,  or  effusions,  will 
depend  largely  on  these  conditions. 

Not  only  must  the  vaginal  vault  be  systematically 
explored,  first  the  cul-de-sac  of  Douglas,  then  at  the 
sides  of  the  cervix,  the  anterior  fornix  of  the  vagina, 
and  the  broad  ligaments,  but  also  the  utero-sacral  liga- 


DIAGNOSIS  OF  PELVIC  PERITONITIS.        335 

rnents,  and  the  posterior  and  upper  surface  of  the  broad 
ligaments  through  the  rectum.  In  some  instances, 
when  the  patient  cannot  resist  the  impulse  to  contract 
the  abdominal  walls,  or  if  the  latter  are  very  fat,  it  will 
be  necessary  to  give  ether  ;  but  this  has  the  great  dis- 
advantage that  spots  of  local  inflammation  or  tender- 
ness may  remain  undetected,  as  she  is  no  longer  sensi- 
tive to  pain. 

The  exudation  varies  in  size  from  a  walnut  to  a  large 
mass  filling  the  pelvis.  In  the  early  stage,  before  adhe- 
sions or  false  membranes  have  formed  to  shut  off  the 
fluid  from  the  peritoneal  cavity,  the  effusion  is  not  likely 
to  be  felt,  as  the  fluid  at  once  yields  to  the  touch  of  the 
finger.  Later,  however,  when  it  is  encapsuled,  and 
becomes  somewhat  hard,  it  is  easily  detected.  In  the 
beginning  it  is  exquisitely  sensitive,  and  slowly  grows 
less  so,  till  it  can  be  readily  handled  without  causing 
much  pain.  Adhesions  can  sometimes  be  felt  like  fine 
strings  extending  from  the  uterus  into  the  adjoining 
tissue,  especially  at  the  angle  of  a  lacerated  cervix. 
The  immobility  of  the  uterus  is  another  indication  that 
these  are  present. 

In  rare  instances,  the  exudation  may  extend  well  up 
above  the  true  pelvis  into  the  abdominal  cavity,  and 
give  rise  to  the  suspicion  of  a  fibroid  or  ovarian  tumor 
with  the  presence  of  sub-acute  peritonitis  ;  but  the  his- 
tory of  the  case,  and  the  variations  in  the  size  of  the 
tumor  in  the  course  of  a  few  days  will  distinguish  it. 
It  enlarges  with  increase  of  pain  from  slight  causes,  and 
diminishes  rapidly,  to  a  certain  extent,  as  the  serum  is 
absorbed. 


33^      PELVIC   CELLULITIS  AND   PERITONITIS. 


DIFFERENTIAL    DIAGNOSIS. 


Fehnc 
Peritonitis. 


Pelvic 
Cellulitis. 


Pelvic 
A bscess. 


Fibroid  or 
Ovarian  Ttimor. 


Hcematocele. 


Develops  with  se- 
vere pain,  extreme 
spnsitiveness,  and 
symptoms  similar 
to  general  peritoni- 
tis. 

Occurs  inde- 
pendent of  the  pu- 
erperal state. 


Exudation  i  m  - 
movable,  and  very 
sensitive,  unless 
far  advanced  in 
chronic  form. 

Tumor  formed 
by  exudation  very 
hard  ;  gradually 
shrinks. 

Tumor  extends 
up,  from  lowest 
point  of  the  cul-de- 
sac  of  Douglas, 
uniformly  around 
the  uterus,  like  set 
plaster-of- Paris,  or 
inutero-sacral  liga- 
ments; less  often, 
at  the  sides  of  the 
uterus.  Frequently 
the  exudation  is 
felt  only  in  roof  of 
the  pelvis. 

Suppuration 
rare. 

Uterus  at  first 
crowded  to  one  side 
by  the  exudation, 
and  drawn  back 
again  and  out  of 
place  as  the  latter 
is  absorbed. 


Development 
not  so  violent  ; 
chill  followed  by 
fever,  but  no  vom- 
iting ;  less  pain 
and  sensitiveness. 

Very  rare,  inde- 
pendent of  the 
puerperal  state  or 
surgical  opera- 
tions. 

Exudation  im- 
movable, sensi- 
tive, but  less  so 
than  the  preceding 
disease. 

Same  as  in  peri- 
tonitis. 


Tumor  most 
often  at  sides  of 
cervix,  or  in  broad 
ligament;  feels 
separate  from  the 
uterus,  and  as  if 
attached  to  the 
walls  of  the  pelvis; 
generally  extends 
lower  in  the  pel- 
vis, and  more  at 
the  side,  than  the 
former. 

S  u  ppu  ration 
more  common. 

Uterus  displaced 
as  in  peritonitis, 
but  no  adhesions 
unless  complicated 
by  peritonitis. 


May  result 
from  either 
cellulitis  or 
peritonitis. 


Immovable; 
not  always 
sensitive. 


Tumor  is 
low  down  in 
the  pelvis,  and 
fluctuates. 

Occupies 
the  site  of  ex- 
udation in  ei- 
ther cellulitis 
or  peritonitis. 


Uterus  dis- 
placed. 


Development 
very  slow,  with- 
out symptoms 
ofinflammation. 


More  common 
at  or  near  the 
climacteric. 


Freely  mov- 
able, and  not 
sensitive. 


Tumor  higher 
up  in  the  pel- 
vis; hard  if  a 
fibroid,  elastic 
if  ovarian. 

Tumor  higher 
in  pelvis,  and, 
if  fibroid,  at- 
tached to  the 
uterus. 


Displacement 
of  uterus  not  so 
marked. 


Develops  sud- 
d  e  n  1  y,  with 
symptoms  of  col- 
lapse and  inter- 
nal hemorihage, 
and  without  rise 
of  temperature. 


Immovable, 
and  sensitiveness 
varies  according 
to  its  duration. 

Tumor  elastic 
and  fluctuating 
in  the  beginning; 
gradually  shrinks 
and  hardens. 

Tumor  begins 
in  lowest  point 
of  the  cul-de-sac 
of  Douglas,  and 
extends  up  in  the 
pelvis  on  an  ap- 
proximate level. 


Uterus  crowd- 
ed forward 
toward  the  pu- 
bis, instead  of 
lateral  displace- 
ment. 


PROGNOSIS   OF  PELVIC  PERITONITIS.         33/ 
Differential  Diagnosis.  —  Concluded. 


Pelvic 

Pelvic 

Pelvic 

Fibroid  or 

Hcematocele. 

Peritojiitis. 

Cellulitis. 

Abscess. 

Ovarian  Titmor. 

Adhesions     are 

Less      movable 

common. 

than  in  former  af- 
fection. 

Often   worse    at 

Not  aggravated 

Menorrhagia 

the  menstrual 

by  the   menstrual 

is   a   prominent 

epochs. 

epochs. 

symptom    of 
uterine  fibroids. 

The  duration  of  pelvic  peritonitis  is  variable ;  and,  from 
the  great  tendency  to  relapses,  it  is  likely  to  continue 
for  an  indefinite  period  without  proper  treatment. 

As  sequelae  may  be  mentioned,  displacement  and 
fixation  of  the  uterus  by  adhesions,  sterility,  atrophy  of 
the  ovaries,  occlusion  of  the  Fallopian  tubes,  amenor- 
rhoea,  and  dvsmenorrhoea. 

The  Prognosis  depends,  of  course,  on  the  extent  of 
the  disease  and  the  severity  of  the  symptoms.  Fortu- 
nately, few  cases  die;  but  complete  recovery  from  this 
affection  requires  great  care,  patience,  and  faithfulness 
in  treatment  on  the  part  of  both  the  patient  and  her 
physician.  In  the  acute  stage,  it  is  a  good  sign  if  the 
pulse  and  temperature  diminish  in  proportion  to  each 
other,  and  if  the  pulse  becomes  fuller,  stronger,  and 
less  rapid,  as  the  pain  subsides.  It  is  a  bad  sign  if  the 
pulse  becomes  quicker  and  weaker  as  the  pain  ceases, 
and  there  is  very  little  chance  for  life  if  the  pain  stops 
suddenly,  the  pulse  flickers,  and  the  features  collapse. 
Death  is  at  hand  when  the  pulse  and  temperature 
become  disproportionate  to  each  other  and  the  extent 
of  the  disease;  i.e.,  the  temperature  falls  to  or  below 
normal,  perhaps  to  96°,  and  the  pulse  growing  rapid  and 
weak,  140  to  150  or  more  per  minute,  even  though  the 
condition  of  the  patient  may  be  good  in  other  respects. 


338      PELVIC  CELLULITIS  AND  PERITONITIS. 

The  exudation  of  pelvic  peritonitis  or  pelvic  cellulitis 
sometimes  undergoes  suppuration  instead  of  absorp- 
tion. While  these  are  far  the  most  common  causes  of 
pelvic  abscess,  there  are  others,  such  as  periproctitis, 
suppuration  of  an  ovarian  cyst,  and  caries  of  any  of  the 
pelvic  bones.  It  follows  pelvic  cellulitis  more  often 
than  pelvic  peritonitis,  and  is  more  common  in  the  puer- 
peral state  than  out  of  it.  The  syphilitic,  scrofulous, 
and  tuberculous  diatheses  are  marked  predisposing 
causes,  as  well  as  a  general  depression  of  the  vital 
forces  or  physical  vigor  of  a  woman.  Pelvic  abscess  is 
also  more  apt  to  follow  when  the  exudation  is  of  septic 
origin.  If,  under  the  above  conditions,  the  fever 
continues  moderately  high,  and  the  exudation  remains 
exquisitely  sensitive  and  does  not  harden,  there  is  good 
reason  to  expect  the  formation  of  an  abscess. 

Though  it  may  develop  insidiously,  with  scarcely  any 
or  no  symptoms,  the  formation  of  pus  is  generally 
characterized  by  chills,  fever,  profuse  perspiration,  pros- 
tration of  the  patient,  throbbing  pain  in  the  pelvis,  dis- 
turbances of  micturition  or  defecation,  or  even  neuralgic 
or  sciatic  pains  in  the  limb  from  the  pressure  of  the 
abscess  on  the  surrounding  structures  ;  persistent  pain 
or  aching  in  the  heel  is  sometimes  observed  in  connec- 
tion with  a  large  pelvic  abscess.  In  rare  instances  the 
fever  symptoms  have  subsided,  and  the  pus  has  been 
retained  for  months  or  even  years.  Generally  the  hectic 
fever  continues,  the  abscess  increases  in  size,  and  breaks 
either  into  the  vagina,  rectum,  bladder,  or  groin,  and, 
least  frequently  of  all,  into  the  peritoneal  cavity,  which 
almost  invariably  causes  a  fatal  attack  of  peritonitis. 

The  diagnosis  is  made  by  the  history  of  the  case  and 
the  presence  of  a  fluctuating  tumor  in  the  pelvis,  ascer- 
tained by  bi-manual  examination,  through  both  the 
vagina  and  rectum. 


PROGNOSIS  OF  PELVIC  ABSCESS.  339 

The  Prognosis  is  favorable  when  the  abscess  has  a 
free  opening  into  the  vagina  and  rectum,  so  that  the 
cavity  is  thoroughly  drained,  if  the  fever  and  purulent 
discharge  diminish,  and  also  if  the  odor  be  not  very 
offensive.  The  prognosis  is  unfavorable  where  there  is 
a  marked  hereditary  taint  of  tuberculosis  or  scrofula,  and 
a  feeble  state  of  health,  if  the  abscess  be  deep-seated, 
and  opens  into  both  bladder  and  rectum,  or  by  a  long 
sinus  which  does  not  permit  a  free  discharge  from  the 
cavity ;  unless  surgical  interference  can  change  these 
conditions. 

There  are  few  diseases  which  test  a  patient's  consti- 
tution and  vigor  more  than  the  constant  drain  of  a  large 
abscess.  It  is  of  great  importance,  therefore,  for  her  to 
eat  the  most  nutritious  food  in  abundance,  — meat-soups 
and  all  the  meat  she  can  digest,  with  milk,  eggs,  and  fresh 
vegetables,  aided  if  necessary  by  some  malt  liquor. 

Treatment.  — Notwithstanding  the  assertions  of  emi- 
nent men  to  the  contrary,  the  writer  feels  positive  from 
results  in  his  own  experience,  that  carefully  selected 
remedies  are  very  beneficial.  The  same  principles  of 
surgery  for  the  treatment  of  abscesses  in  other  por- 
tions of  the  body  apply  equally  here.  The  collection  of 
pus  must  be  evacuated  by  as  free  an  incision  as  is  con- 
sistent with  safety.'  Mr.  Lawson  Tait  prefers  to  reach 
the  abscess  through  the  abdominal  wall,  and  to  use  a 
drainage-tube  afterwards.  The  more  usual  method  of 
opening,  however,  is  to  expose  the  lowest  point  of  the 
abscess  with  a  Sims'  speculum,  insert  the  needle  of  an 
aspirator,  and,  when  pus  is  found,  run  a  narrow-bladed 
bistoury  along  the  needle  as  a  guide.  This  opening  is 
very  cautiously  enlarged  enough  to  allow  a  free  dis- 
charge of  the  pus,  which  is  generally  very  offensive, 

'  American  Journal  of  Obstetrics,  P.  F.  Munde.  Report  of  Ten  Cases,  p.  113, 
February,  1886. 


340      PELVIC  CELLULITIS  AND   PERITONITIS. 

and  the  cavity  is  thoroughly  cleansed  with  a  weak  solu- 
tion of  carbolic  acid,  or  bi-chloride  of  mercury  (i  :  3000), 
without  allowing  the  water  to  flow  with  any  force  from 
the  syringe.  A  drainage-tube  is  then  inserted,  and  a 
little  iodoform  or  sublimate  gauze  packed  in  the  vagina. 
Irrigation  of  the  cavity  with  one  of  the  above  solutions 
will  be  necessary  once  or  twice  a  day,  or  less  often, 
according  to  the  quality  and  quantity  of  the  discharge. 
There  are  few  places  in  the  body  where  it  is  more  haz- 
ardous to  plunge  a  knife  than  here,  so  that  it  behooves 
a  physician  to  guard  against  all  possible  mistakes  and 
the  wounding  of  large  blood-vessels.  If  the  abscess 
opens  through  a  long  sinus,  and  has  become  chronic, 
it  will  be  necessary  to  dissect  the  sinus  out  and  make 
an  opening,  which  permits  the  free  flow  of  pus,  and 
the  irrigation  of  the  cavity  of  the  abscess. 

The  Ti'eaiment  of  pelvic  cellulitis  does  not  differ  from 
that  of  pelvic  peritonitis  in  the  stage  of  effusion  and 
induration.  In  the  very  commencement  of  the  stage 
of  congestion,  with  the  initial  chill,  cellulitis  can  often 
be  abated  by  the  immediate  and  continuous  use  of  the 
hot-water  douche.  The  patient  must  be  warmly  blank- 
eted, with  a  hot-water  bottle  or  heated  bricks  at  her 
feet,  and  the  injection  continued  till  re-action  is  estab- 
lished, the  fever  subsided,  and  free  perspiration  has 
commenced.  The  hot-water  spinal  bag  applied  to  the 
lumbo-dorsal  region  is  worthy  of  trial,  in  the  hope  that 
it  will  contract  the  pelvic  blood-vessels  and  diminish 
the  congestion. 

This  same  treatment  can  be  adopted  for  slight  attacks 
of  pelvic  peritonitis,  but  in  the  acute  stage  of  the  severe 
forms  there  would  be  danger  of  aggravation.  In  both 
these  diseases,  especially  the  latter,  absolute  rest,  while 
acute  symptoms  are  present,  cannot  be  over-estimated. 
The  patient  must  be  waited  on  like  an  infant,  without 


TREA  TMENT.  3  4 1 

the  least  voluntary  motion  of  any  kind  on  her  part.  In 
peritonitis,  opium  in  some  form  is  the  sheet-anchor  of 
the  old  school,  both  to  allay  pain  and  secure  additional 
quiet  ;  but  it  has  the  disadvantage  of  causing  consti- 
pation and  faecal  impaction,  which  interferes  with  free 
portal  circulation,  and  in  consequence  materially  hinders 
recovery.  The  removal  of  a  collection  of  faeces,  it 
present,  is  one  of  the  first  things  to  be  attended  to  by 
the  practitioner. 

As  long  as  there  are  symptoms  of  local  inflammation, 
rest  is  essential,  particularly  at  the  menstrual  period. 
A  hammock  is  one  of  the  most  comfortable  things  for 
the  patient  to  lie  in.  Coition  is  a  positive  injury.  The 
sewing-machine,  and  walking,  riding,  or  any  exercise 
which  aggravates  the  pain,  are  to  be  positively  forbid- 
den, and  high-heeled  shoes  in  particular.  Hot-water 
injections  '  are  invaluable  so  long  as  any  exudation  is 
present,  to  stimulate  the  pelvic  circulation,  and  thus 
promote  absorption.  The  writer  has  obtained  excellent 
results  in  some  cases  by  medicating  the  last  pint  of  the 
injection  with  glycerine,  iodine,  or  hamamelis. 

In  case  the  uterus  is  out  of  place,  and  drags  on  the 
ligaments,  much  good  can  be  done  by  inserting  every 
other  day  an  antiseptic  wool  tampon,  so  as  to  raise  that 
organ  up,  and  thus  remove  a  source  of  irritation;  taking 
care,  however,  that  the  tampon  does  not  press  against 
the  sensitive  effusion  and  cause  pain.  This  same  tampon 
can  be  impregnated  with  iodine  and  glycerine,  which  is 
the  best  application  the  writer  has  so  far  used  for  these 
cases  when  of  long  duration.  In  the  early  stages,  bella- 
donna cerate  or  extract  is  superior,  and  iodol  or  iodo- 
form has  a  more  soothing  effect  than  either.  When 
there  is  much  active  inflammation,  tampons  cannot  be 
endured,    and   the   belladona,  iodoform,    or   any    other 

'  See  chapter  on  Minor  Surgical  Gynaecology. 


342      PELVIC  CELLULITIS  AND  PERITONITIS. 

cerate  can  be  applied  with  an  ointment  injector,  or  the 
medicament  can  be  used  in  a  suppository.  Where  there 
is  much  congestion,  and  but  little  inflammation,  with  a 
great  deal  of  dragging  on  the  uterine  ligaments,  Hof- 
man's  pessary  will   give  much  relief,  and   is   easier  to 

wear  than  a  hard  rubber  in- 
strument. Like  all  soft  rubber 
pessaries,  it  will  absorb  secre- 
tions, and  requires  constant 
attention,  or  it  will  become 
very  offensive.  Some  of  these 
pessaries  have  a  rubber  cup 
^     „  attached  to  hold  a  cerate  for 

Fig.  84. 

application,  but  the  writer 
finds  it  difficult  to  make  much  practical  use  of  it. 

In  connection  with  these  pessaries,  a  carefully  fitted 
abdominal  supporter  will  give  great  relief  in  taking  off 
a  certain  amount  of  pressure  from  above.  The  diet 
must  be  the  most  nutritious  possible,  and  so  regulated 
as  to  secure  a  daily  movement  from  the  bowels.  In 
cases  of  exudation  in  the  utero-sacral  ligaments  and 
much  irritation  at  the  neck  of  the  bladder.  Dr.  Emmet 
has  found  it  necessary  to  prolong  the  incision  in  the 
button-hole  operation  for  prolapse  of  the  urethra,  so 
as  to  free  the  fascia  at  the  neck  of  the  bladder,  and 
thus  relieve  the  constant  inclination  to  urinate. 

The  galvanic  current  has  met  with  some  favor  in  the 
treatment  of  these  diseases,  to  promote  the  absorption 
of  both  exudations  and  adhesions.  The  negative  pole  is 
^sed  in  the  vagina  for  this  purpose,'  and  the  positive 
pole  in  the  same  place,  instead  of  the  negative,  if  a 
palliative  or  soothing  effect  is  desired  ;  but  it  is  always 
counter-indicated  when  acute  inflammatory  symptoms 
are  present. 

'  Dr.  A.  D  Rockwell,  The  Medical  Record,  p.  627,  vol.  ii.  1885. 


THERAPEUTJCS.  343 

THERAPEUTICS    OF    PELVIC    CELLULITIS,    PELVIC 
PERITONITIS,    AND    PELVIC    ABSCESS. 

"  I  Aconite.'  A  valuable  remedy  in  the  stage  of  congestion 
(Veratr.  vir.),  especially  when  it  results  from  cold  ;  high  fever; 
hot,  dry  skin ;  great  thirst ;  much  anxiety  and  restlessness. 
Vomiting  is  sometimes  present,  and  cutting  pains  in  the  abdo- 
men. It  should  be  given  in  the  lower  potencies,  in  severe 
cases  (ix.  or  2x.)  as  often  as  once  in  fifteen  or  twenty  minutes, 
till  the  fever  begins  to  subside,  and  perspiration  commences. 
It  is  most  useful  at  the  time  when  the  hot-water  douche  is 
indicated.  Dr.  Jousset^  recommends  twenty  to  thirty  drops 
of  the  mother  tincture  to  be  taken  in  twenty-four  hours,  for 
very  acute  and  severe  cases  of  pelvic  peritonitis. 

I  Apis  3X.  trit.  will  sometimes  abort  suppuration.  It  is  good 
for  relapsing  abscesses,  and  is  one  of  the  most  useful  remedies 
to  stimulate  the  absorption  of  exudation.  Apis  is  to  effusion 
in  the  cellular  tissue,  what  bryonia  is  to  effusion  of  serum  in  the 
peritoneum.  Burning,  stinging  pain  in  region  of  the  uterus  or 
ovaries,  especially  tlit  right ;  great  tenderness  over  the  uterine 
region,  with  bearing-down  pain  ;  leucorrhoea  and  painful  urina- 
tion ;  menses  diminished  or  suppressed  ;  tendency  to  anasarca. 

Arnica.  Dr.  Ludlam  ^  writes  that  for  traumatic  cellulitis 
there  is  no  treatment  to  compare  with  the  avoidance  of  the 
exciting  cause,  and  the  internal  use  of  arnica.  When  the 
patient  is  of  the  hemorrhoidal  or  hemorrhagic  diathesis,  hama- 
melis  is  equally  good. 

I  Arsenicum.'*  In  pelvic  peritonitis,  when  the  effusion  is 
copious,  and  the  amount  varies  somewhat  at  intervals  of  a  few 
days ;  the  patient  asthenic  and  much  prostrated,  suffers  from 
great  thirst ;  burning  pains  in  the  abdomen,  worse  in  the  latter 
part  of  the  afternoon,  and  after  midnight. 

'  Dr.  Bailey:  Aconite  in  Pelvic  Cellulitis,  Clinique,  vol.  v.  p.  301, 

^  Lectures  on  Clinical  Medicine,  pp.  265-299.     Chicago,  iSSo. 

3  Clinique,  July,  18S1. 

*  Dr.  CI.  Miiller  cured  a  very  interesting  case  reported  as  scirrhus  uteri,  but  it 
is  quite  as  likely  that  it  was  one  of  chronic  inflammation  and  induration.  —  Horn. 
Viertelj ahrschrift ,  vol.  iii.  p.  246. 


344       PELVIC  CELLULITIS  AND  PERITONITIS. 

Belladonna  is  a  good  remedy  for  both  pelvic  peritonitis 
and  cellulitis,  particularly  the  latter.  It  is  most  suitable  to  the 
acute  stage,  and  may  arrest  the  inflammation  if  given  early  and 
often.  The  fever  is  less  violent  than  that  calling  for  aconite, 
and  is  useful  in  the  puerperal  state,  when  the  lochia  are  sup- 
pressed ;  the  vagina  hot,  dry,  and  sensitive ;  throbbing  of  the 
blood-vessels  in  the  pelvis  ;  throbbing  headache  ;  flushed  face  ; 
eyes  brilliant ;  abdomen  painfully  distended,  with  much  heat, 
burning  and  cutting  pains.  In  the  "  Clinique  "  for  July,  1881, 
Dr.  Ludlam  says  he  has  had  excellent  results  in  sub-acute  cases 
of  cellulitis  with  belladonna  3  and  apis  3  in  alternation. 

Bryonia  follows  aconite  or  belladonna  well  in  pelvic  per- 
itonitis, to  absorb  the  effusion  of  serum  (Scilla  mar.}.  As 
Baehr  says,  the  remedy  must  be  used  consistently.  We  can- 
not expect  to  obtain  results  in  a  day  that  can  only  be  obtained 
in  ten  days  or  a  fortnight.  It  may  also  be  useful  in  cases  of 
pelvic  inflammation,  which  appear  to  be  connected  with  metas- 
tasis of  rheumatism  (Macrotin,  rhus).  It  is  indicated  by 
stitching,  lancinating  pains  in  the  hypogastrium,  worse  by  the 
least  motion ;  motion  sometimes  causes  vomiting ;  great  thirst 
for  large  quantities  of  water ;  very  dry  mouth,  lips,  and  tongue 
which  is  thickly  coated  white ;  obstinate  constipation. 

Calcarea  carb.,  Calcarea  iod.,  and  Calcarea  fluor. 
are  important  remedies,  when  the  exudation  has  taken  place  in 
scrofulous  or  tuberculous  women,  and  an  abscess  is  threatening, 
or  has  already  formed.  Calcarea  iod.  has  more  power  in  pro- 
moting resolution  than  calcarea  carb.,  but  both  are  sometimes 
indispensable  for  their  constitutional  effects.  Too  early  and 
profuse  menstruation  is  one  of  the  many  keynotes  in  selecting 
this  remedy.  The  most  important  general  indication  is  the 
scrofulous  diathesis  (Lach.,  mere,  iod.,  silicea,  sulphur).  Cal- 
carea fluor.  is  an  invaluable  remedy  for  pelvic  abscess  proceed- 
ing from  caries  of  some  bone. 

Cantharis  is  mentioned  by  Dr.  Jousset  as  one  of  the  medi- 
cines particularly  adapted  to  the  acute  stage  of  pelvic  peritonitis 
(Aeon.,  coloc).  Great  sensitiveness  and  distension  of  the 
abdomen,  with  violent  burning  and  cutting  pains ;  hard  tume- 


THERA  PE  (7  TICS.  345 

faction  above  the  symphysis  pubis,  with  burning  pains  in  the 
loins ;  tenesmus  of  the  bladder,  strangury,  great  anguish  and 
restlessness. 

China.  Chronic  pelvic  abscess,  where  the  patient  has 
become  debilitated  from  the  long-continued  discharge  of  pus; 
fever  of  an  intermittent  or  remittent  type. 

Colocynth,  In  the  acute  stage  of  pelvic  peritonitis,  with 
little  effusion,  especially  in  the  left  ovarian  region.  Violent, 
cutting,  tearing  pains,  relieved  somewhat  by  pressure  ;  frequent 
tenesmus  of  the  bladder,  with  scanty  urine  ;  diarrhoea,  and 
tenesmus  of  the  rectum.  It  is  highly  recommended  by  Drs. 
Jousset  and  Hughes. 

Conium.  Tympany  of  the  abdomen,  especially  at  the 
menstrual  epochs  ;  severe  pain  in  the  abdomen,  with  chilliness  ; 
violent  cutting  pains  in  the  abdomen;  aching  and  bearing-down 
pain  in  the  hypogastrium ;  leucorrhoea  of  white,  acrid  mucus, 
causing  a  burning  sensation,  and  preceded  by  colic-like  pains  ; 
frequent  urination  at  night ;  burning  or  smarting  in  the  urethra 
during  and  after  micturition ;  induration  of  uterus,  ovaries,  or 
breasts  ;  sweUing  and  soreness  of  the  mammce  before  the  menses. 
Dr.  Ludlam '  praises  it  warmly  in  the  2X.  dil.,  and  thinks  it  is 
equally  adapted  to  both  the  chronic  and  puerperal  forms  of 
pelvic  peritonitis.     Bernutz  ^  found  it  very  useful. 

Hepar  sulphur  is  the  best  remedy  to  hasten  suppuration 
when  it  is  inevitable,  but  it  must  not  be  used  during  suppura- 
tion unless  we  wish  to  increase  it. 

I  Macrotin.  Cases  of  sub-acute  pelvic  peritonitis  in  rheu- 
matic women,  subject  to  pleurodynia,  intercostal  rheumatism, 
etc.  Painful  condition  of  the  spinal  muscles.  If  the  patient 
is  in  an  anxious,  nervous,  irritable  condition ;  takes  no  interest 
in  any  thing ;  despondent,  sleepless ;  suffers  from  pain  and  dis- 
tress in  the  pelvis  ;  and  the  menses  are  scanty  or  irregular,  with 
increased  nervousness  at  the  time  of  their  appearance. 

1  Mercurius.3    Formerly  the  solubilis  was  the  favorite  prep- 

'  Note  in  Joiisset's  Clinical  Med.,  Am.  ed.,  p.  285. 

2  Bernutz  and  Goupil,  Clin.  Memoirs  on  Dis.  of  Women,  vol.  ii.  p.  165. 

3  Dr.  Clotar  MUller  cured  an  interesting  case  with  mere,  sol.,  3X.  trit.,  in  which 
the  following  symptoms  were  prominent.    A  young  woman,  aged  twenty-eight,  had 


346      PELVIC   CELLULITIS  AND   PERITONITIS. 

aration  ;  but  on  account  of  its  instability  this  has  given  way 
to  the  corrosivus,  vivus,  or  iodide.  It  is  a  good  remedy  for  the 
exudation  of  either  cellulitis  or  peritonitis  with  the  tendency,  to 
the  formation  of  pus,  or  in  the  beginning  of  pelvic  abscess.  It 
has  also  been  serviceable  to  promote  the  absorption  of  exuda- 
tions appearing  after  confinement.  The  indications  for  it  are, 
creeping  chills:  much  perspiration  without  relief;  great  weak- 
ness and  prostration  ;  pale,  earthy  complexion ;  bad  odor  from 
the  mouth ;  abdomen  hard,  distended,  and  painful ;  mucous 
stools,  with  burning  and  tenesmus  ;  oedema  of  the  feet ;  and  fre- 
quent desire  to  urinate,  with  scanty  discharge.  It  is  not  likely 
that  all  these  symptoms  will  be  found  in  one  case  ;  but  there  will 
be  a  combination  of  them,  with  other  characteristics  of  the 
drug,  which  will  point  to  the  remedy. 

Opium  is  useful  for  the  obstinate  constipation  depending 
on  the  paralytic  condition  of  the  intestines  during  or  after  the 
disappearance  of  the  exudation.  It  is  well  to  ascertain  first  if 
it  had  been  given  previously,  in  physiological  doses,  and  thus 
caused  the  constipation ;  in  which  case  nux  vom.,  plumbum,  or 
sulphur  would  be  more  suitable. 

Salicylate  of  soda  ix.  Dr.  Ludlam  has  found  this  use- 
ful, where  there  is  an  appar^^nt  metastasis  of  rheumatic  inflam- 
mation to  the  peritoneum.  "  It  is  indicated  for  the  relief  of 
the  intra-pelvic  pain  and  distress,  especially  when  it  is  of  a  neu- 
ralgic or  rheumatic  character ;  but  the  more  acute  the  case,  and 
the  more  decided  the  diminution  in  the  quantity  of  the  urine 

been  delivered  six  months  previous  to  his  visit.  In  a  few  days  after  her  confine- 
ment the  present  attack  of  pelvic  peritonitis,  cellulitiis,  and  ovaritis  developed, 
rather  more  in  the  left  than  in  the  right  side.  Violent  pressing,  shooting  pain  in  the 
hypogastrium,  especially  the  left  side  ;  worse  at  night,  on  motion,  defecation,  and 
micturition.  Had  to  lie  on  her  back  with  thighs  drawn  up  ;  obstinate  constipation  ; 
almost  constant  desire  to  urinate,  with  scanty,  reddish  urine ;  great  thirst,  coated 
tongue,  foul  taste,  and  no  appetite;  foetid  perspiration  ;  slight  oedema  of  the  feet ; 
small  frequent  pulse ;  extreme  weakness  and  emaciation.  Improvement  began  at 
once  after  taking  mere.  sol. ;  and  the  patient  was  sitting  up  some  hours  at  a  time 
in  less  than  four  weeks,  and  continued  to  gain  rapidly.  She  had  no  other  remedy 
than  mere,  sol.,  except  nux  vom.  for  three  days.—  Horn.  Vicrtcljahrschrift,  vol. 
iii.  p.  246.  The  period  of  convalescence  may  seem  long,  but  those  who  have  had 
experience  in  treating  bad  cases  will  consider  it  unusually  good  progress. 


THERAPEUTICS.  347 

secreted,  and  the  absolute  increase  in  the  proportion  of  uric 
acid  contained  in  the  urine,  the  better  the  indication." 

Silicea.  Chronic  pelvic  abscess  with  fistulous  opening 
(Phos.),  and  large  amount  of  thin  pus.  Constant  chilliness; 
fever,  with  violent  heat  in  the  head,  worse  at  night ;  profuse, 
sour  or  offensive  perspiration  at  night ;  much  weakness  and 
prostration ;  great  constipation,  constant  but  ineffectual  desire 
for  stool ;  stool  expelled  with  difficulty,  or  when  partially  ex- 
pelled slips  back ;  headache  and  nervous  symptoms,  which  seem- 
to  depend  on  the  drain  from  suppuration. 

Sulphur  is  sometimes  used  after  bryonia,  to  hasten  absorp- 
tion of  the  effusion.  It  is  excellent  in  chronic  cases,  especially 
in  scrofulous  persons,  to  promote  absorption  for  abscesses,  and, 
intercurrently,  to  aid  the  action  of  other  remedies.  Chilliness, 
flushes  of  heat,  profuse  night-sweat,  great  prostration,  constipa- 
tion, and  a  hemorrhoidal  tendency,  are  prominent  characteris- 
tics of  this  remedy. 

Tartar  emetic  has  proved  so  useful  in  hyperplasia  of  the 
cervix,  it  has  been  tried  and  found  useful  for  removing  small 
indurations,  which  are  not  very  hard,  in  women  who  enjoy  good 
health  in  other  respects. 

I  Terebinthina  2x.  is  another  remedy  in  which  Dr.  Lud- 
1am  has  great  confidence  for  puerperal  and  post- puerperal  pelvic 
peritonitis.  When  there  is  great  weakness  and  prostration, 
excessive  distension  of  the  abdomen,  and  a  disposition  to  hem- 
orrhage, which  makes  it  useful  in  peritonitis,  associated  with 
pelvic  hsematocele.  The  violent  drawing,  burning  pains  in  the 
region  of  the  kidneys ;  scanty  and  bloody,  or  even  suppressed 
urine,  with  distressing  strangury,  —  are  excellent  additional  indi- 
cations, should  they  be  present. 

Veratrum  viride  2x.  has  been  warmly  recommended  for 
the  acute  stage  of  pelvic  cellulitis  or  peritonitis  in  lying-in 
women,  with  symptoms  similar  to  those  calling  for  aconite. 
Great  cerebral  congestion  ;  pupils  dilated  ;  face  flushed  ;  violent 
nausea  and  vomiting,  with  cold  sweat ;  severe  pain  and  soreness 
just  above  the  pelvis ;  heart-beats  loud  and  strong,  with  great 
arterial  excitement,  but  the  respirations  are  very  slow.     The 


348      PELVrC   CELLULITIS  AND   PERITONITIS. 

doses  must  be  frequently  repeated,  till  there  is  some  ameliora- 
tion of  the  symptoms. 

Remedies  for  Pelvic  Cellulitis.  — Aeon.,  apis,  arnica, 
ars.,  bell.,  bry.,  calc.  carb.  and  iod.,  canth.,  colch.,  dig., 
hellebore,  kali  iod.,  mere,  viv.,  rhus  tox.,  sulphur,  tartar 
emetic,  veratr.  vir. 

Remedies  for  Pelvic  Peritonitis. — Aeon.,  apis,  ars., 
bell.,  bry.,  canth.,  carbo  veg.,  coloc,  iach.,  lil.  tig.,'  ma- 
crotin,  mere.  cor.  or  iod.,  nitric  ac,  nux  vom.,  rhus  tox., 
scilla  mar.,  salicylate  of  soda,  terebinthina,  veratr.  vir. 

Remedies  for  Pelvic  Abscess.  —  Calc.  carb.,  calc.Jluo- 
rata,  carbo  an.,  china,  Jiepar  snlpJi.,  mere,  viv.,  phos., 
silicea,  sulphur. 

'  Various  observers  report  differently  concerning  this  remedy,  some  praising  it 
warmly.  I  have  been  very  often  disappointed  by  it ;  but  Dr.  H.  H.  Read,  as  well 
as  others,  has  had  good  results  from  it. 


PELVIC  HEMATOCELE. 


349 


CHAPTER    XXIII. 


PELVIC      H/EMATOCELE. 


AS  the  name  implies,  it  is  a  collection  of  blood  in  the 
pelvic  cavity.  It  is  so  rare,  that  comparatively 
iew  practitioners  ever  meet  v^ith  this  affection  ;  but 
when  it  does  occur,  it  is  most  often  at  the  menstrual 
period  in  vi'omen  from  twenty-five  to  thirty-five  years  of 
age.  The  effusion  of  blood  may  be  within  the  perito- 
neal cavity,  intra-peritoneal ;  or  extra-peritoneal,  without 
the  peritoneum,  in  the  cellular  tissue.  The  former  is 
the  more  common,  and  the  latter  is  pretty  sure  to  break 
into  the  peritoneum  if  that  membrane  is  put  on  the 
stretch  by  a  large  exudation  in  the  cellular  tissue.  The 
causes  are  numerous,  but  may  be  classified  as  pre- 
disposing and  exciting. 

f  Lowered  vitality  of  the  system. 
Predisposing  causes  \  Frequent  childbearing. 

Hemorrhagic  or  hemorrhoidal  diathesis. 

f  Arterial  aneurism. 

I 

Varicose  veins  in  the  pelvis. 
Extra-uterine  pregnancy. 
I  Phosphorus  poisoning.' 
Pelvic  peritonitis. 
Hemorrhagic  peritonitis. 
Reflux  of  blood  from  uterus  in  conse- 
quence of  obstruction  to  the  menstrual 
flow. 
.  Traumatism. 

'  The  walls  of  the  blood-vessels  undergo  fatty  degeneration,  which  leads  to 
rupture  and  hemorrhage. —  Wegner  :   Virchcw's  Arch.,  vol.  Iv.  p.  12,  1872. 


I 


Exciting  causes 


Rupture 
of  blood-   -I 
vessels 


3 so  PELVIC  HEMATOCELE. 

The  more  common  causes  are  hemorrhagic  pelvic 
peritonitis,  extra-uterine  pregnancy,  and  varicose  veins 
in  the  broad  ligaments  ;  all  others  are  exceedingly  rare 
in  comparison.  It  may  be  worth  v^hile  to  note  that 
hemorrhoids  would  be  very  likely  to  attend  varicosis  of 
the  pelvic  veins. 

The  effusion  of  blood  naturally  gravitates  downward, 
undergoes  partial  coagulation,  and,  if  intra-peritoneal, 
at  the  same  time  causes  sub-acute  pelvic  peritonitis.  A 
false  membrane  soon  forms,  shutting  off  the  blood  from 
the  upper  part  of  the  peritoneal  cavity,  and  encapsuling 
the  fluid.  If  bleeding  takes  place  inside  the  tumor  thus 
formed,  it  becomes  tense  in  proportion,  displacing  the 
uterus  and  the  surrounding  organs.  Large  hsematoceles 
very  often  suppurate,  and  usually  discharge  into  the 
rectum  ;  otherwise,  the  fluid  portion  is  soon  absorbed, 
leaving  a  solid  tumor,  which  only  disappears  after  a  long 
period.  While  it  is  a  fact  that  hsematoceles,  or,  as  they 
have  been  sometimes  called,  haematoma,  are  posterior 
to  the  uterus  in  the  very  great  majority  of  cases,  yet 
instances  have  been  recorded  of  ante-uterine  hasmato- 
cele  ;  and  the  physician  must  be  wary  how  he  decides 
adversely,  because  there  is  no  retro-uterine  tumor  when 
the  symptoms  of  this  affection  are  present. 

It  is  evident  that  the  symptoms  will  be  those  attend- 
ing the  loss  of  blood  from  any  portion  of  the  body,  and 
also  those  accompanying  a  mild  attack  of  peritonitis. 
The  severity  of  the  former  will  depend  on  the  rapidity 
and  amount  of  the  hemorrhage.  The  pain  of  the  latter 
may  be  very  slight  if  the  blood  oozes  slowly  into  the 
peritoneal  cavity,  exciting  little  inflammation  ;  or  amount 
to  the  most  intense  agony  conceivable,  which  no  amount 
of  morphine  can  relieve,  when  the  effusion  of  blood 
takes  place  rapidly  outside  the  peritoneum,  dissecting 
that  membrane  up  from  the  underlying  tissues. 


CLINICAL   HISTORY  OF  HALMATOCELE.       35  ^ 

The  formation  of  a  very  small  ha^matocele  is,  no 
doubt,  often  overlooked  ;  but  the  clinical  Jiistory  of  an 
average  case  can  be  briefly  stated  as  follows  :  The 
attack  is  sometimes,  but  not  always,  preceded  by  a  sense 
of  fulness  and  weight  in  the  pelvis  ;  the  patient  feels 
faint  and  exhausted  ;  grows  paler,  the  features  becom- 
ing pinched,  and  the  extremities  cold  in  collapse  ;  the 
pulse  grows  weak  and  more  rapid  with  much  pain  in  the 
pelvis;  nausea  and  vomiting  ;  the  temperature  is  at  or 
below  normal  ;  and  there  is  severe  rectal  and  vesical 
tenesmus  from  the  pressure  on  the  rectum  and  bladder. 
At  the  same  time,  she  has  a  sense  of  something  in  the 
pelvis ;  bears  down,  and  tries  to  expel  it,  as  in  the  sec- 
ond stage  of  labor.  This  may  be  termed  the  acute  or 
formative  period,  and  varies  from  minutes  to  hours,  or 
even  days. 

Re-action  from  the  prostration  commences,  as  a  rule, 
within  forty-eight  hours.  There  is  a  rise  of  pulse  and 
temperature,  symptoms  of  sub-acute  peritonitis,  and 
constipation.  The  tumor  at  once  begins  to  diminish  in 
size  as  the  serum  is  absorbed,  unless  repeated  hemor- 
rhage take  place,  and  from  an  obscurely  fluctuating  or 
tense  mass,  it  soon  becomes  hard  and  defined,  extending 
up  into  the  pelvis  from  the  lowest  point  of  the  cul-de- 
sac  of  Douglas.  On  vaginal  examination,  a  tumor  is 
found  almost  always  posterior  to  the  uterus,  and  press- 
ing that  organ  forward  against  the  bladder.  It  varies 
in  size  and  consistence  according  to  the  amount  of 
blood  lost  and  its  duration.  It  may  be  no  larger  than  a 
pullet's  &gg,  or  extend  up  to  the  navel.  At  first  soft 
and  resisting,  it  gradually  hardens,  and  in  time  dis- 
appears as  above  stated.  The  posterior  vaginal  wall  is 
crowded  forward,  and  the  rectum  more  or  less  occluded 
by  the  mass.  The  vaginal  touch  in  connection  with 
the  symptoms  just    described   will    be  sufficient  for  a 


352  PELVIC  HALMATOCELE. 

diagnosis.  In  doubtful  cases  an  aspirator  can  be  used, 
taking  care  to  push  the  cannula  beyond  the  clots  into 
the  serum.  For  differential  diagnosis,  compare  the 
chapter  on  pelvic  cellulitis  and  peritonitis. 

The  Pi'ognosis  is  good  for  most  cases  when  they  are 
treated  on  the  expectant  plan.  It  depends  on  the 
amount  of  shock,  and  the  extent  of  the  inflammatory 
re-action  which  follows. 

The  Treatment.  —  If  there  is  reason  to  think  hemor- 
rhage is  still  going  on,  an  attempt  to  arrest  it  can  be 
made  by  placing  pounded  ice  or  ice-water  compresses 
over  the  hypogastrium,  and  giving  cold-water  enemas. 
The  bodily  warmth  must  be  maintained,  and  prostration 
combated,  by  applying  hot  bricks,  hot-water  bottles,  or 
hot  flannels  to  the  extremities,  and  by  frequently  repeated 
doses  of  brandy  and  milk.  If  it  cannot  be  retained, 
and  collapse  is  imminent,  give  brandy  hypodermically  in 
two-drachm  doses  ;  and  if  no  re-action  follows,  ether  in 
half-drachm  doses  in  the  same  way.  When  the  pain  is 
intense,  it  may  become  necessary  to  give  morphine  ; 
but  this  should  be  avoided  so  far  as  possible,  and  the 
pain  mitigated  by  a  few  whiffs  of  ether  or  chloroform. 
The  constant  attention  necessary  for  the  latter  may 
prove  very  irksome  ;  but  the  constipation  following  the 
use  of  morphine  interferes  with  free  portal  circulation, 
and  the  varicosed  veins,  if  present,  are  more  liable  to 
become  distended,  and  again  cause  hemorrhage.  When 
the  pain  is  excessive  from  the  extreme  distension  and 
pressure  on  the  neighboring  organs,  the  tumor  can  be 
aspirated  by  pushing  the  cannula  in  through  the  clots 
till  the  serum  is  reached. 

It  is  hardly  necessary  to  add  that  absolute  rest,  as  far 
as  possible,  is  essential  both  at  this  period  and  till  the 
acute  symptoms  have  subsided.  Plenty  of  water  to 
allay  the  thirst  and  supply  the  system  with  fluid,  besides 


TREATMENT  OF  PELVIC  HEMATOCELE.    353 

small  quantities  of  milk  and  beef-juice  at  short  intervals, 
are  of  prime  importance.  Coitus  must  be  absolutely 
prohibited  for  several  months  afterward.  If  suppura- 
tion commences,  which  is  generally  marked  by  chills, 
hectic  fever,  profuse  perspiration,  and  softening  of  the 
tumor,  it  must  be  opened  and  treated  the  same  as  a 
pelvic  abscess.  Otherwise,  it  is  better  not  to  meddle 
by  surgical  measures,  but  trust  to  nature. 

Medical  Treatment.  —  As  the  accident  must  have 
occurred  before  the  physician  is  called  upon  to  treat  it, 
there  is  little  for  medicine  to  do  more  than  to  promote 
absorption,  sustain  the  patient,  control  the  complica- 
tions so  far  as  possible,  and,  lastly,  to  prevent  recur- 
rence. The  reader  is  referred  to  the  chapter  on  Pelvic 
Peritonitis  for  its  treatment,  —  as  this  is  the  most  com- 
mon complication,  —  and  for  the  promotion  of  absorp- 
tion. The  following  remedies  are  suggested,  thouo:h 
the  writer  has  not  been  able  to  find  recorded  cases  in 
Mrhich  all  have  been  used  :  — 

If  the  hemorrhage  is  still  going  on.  —  Aeon.,  arnica, 
dig,  ham.,  phos.,  millefol,  secale,  terebinthina,  thlaspi 
bursa  pastoris. 

To  promote  absorption.  — Apis,  ars.,  kali  iod.,  mere. 

Ancemia  from  loss  of  blood.  — Ars.,  china,  ferrum. 

To  prevent  recurrence,  especially  itt  women  subject  to 
pelvic  congestion  and  hemorrhoids.  —  ^sculus  hippo., 
bell.,  collinsonia,  ham.,  nux  vom.,  sepia,  suiph. 


354      DISEASES  OF  THE  FALLOPIAN  TUBES. 


CHAPTER    XXIV. 

DISEASES    OF    THE    FALLOPIAN    TUBES. 

MALFORMATIONS,  displacements,  strictures,  and 
abnormal  patency  of  these  tubes  rarely  occur,  but 
do  not  admit  of  diagnosis  except  possibly  by  abdominal 
incision,  or  of  treatment  unless  by  the  radical  method 
of  removal.  A  few  instances  have  been  recorded  where 
the  uterine  sound  has  passed  from  the  uterine  cavity 
into  the  Fallopian  tube.  These  conditions,  therefore, 
have  no  practical  value  in  relation  to  our  present  meth- 
ods of  diagnosis  and  treatment,  and  will  not  be  consid- 
ered further. 

Salpingitis — inflammation  of  the  Fallopian  tubes  — 
occurs  in  the  form  of  acute  or  chronic  catarrh  of  the 
mucous  membrane  lining  their  cavities.  When  the 
fimbriated  extremity  is  closed  either  by  the  catarrh,  or 
more  often  by  the  accompanying  peritoneal  inflamma- 
tion and  the  formation  of  adhesions,  the  secretion  can- 
not always  escape  into  the  uterus  as  fast  as  it  is  formed, 
and  dilatation  of  the  tube  results.  Sometimes  both  the 
uterine  and  fimbriated  extremities  are  closed.  The 
name  of  the  tumor  thus  formed  varies  with  its  contents  : 
dropsy  of  the  tube,  or  hydrosalpinx,  when  the  contents 
are  serum,  mucus,  or  a  mixture  of  both  ;  hsematosal- 
pinx,  when  there  is  a  large  admixture  of  blood  ;  and 
pyosalpinx,  if  the  contents  are  purulent.  A  differential 
diagnosis  between  these  forms  on  the  living,  laparotomy 


SALPINGITIS.  355 

excepted,  is  impossible,  as  the  use  of  the  aspirator  and 
a  microscopic  examination  of  the  contents  are  rarely 
practicable. 

Salpingitis  seldom  if  ever  occurs  as.  a  primary  affec- 
tion. Both  tubes  are  usually  involved.  It  is  the  result 
of  the  extension  of  inflammation  from  the  surrounding 
structures,  and  is  chiefly  caused  by  gonorrhoea,  endo- 
metritis (especially  the  puerperal  form),  and  pelvic  peri- 
tonitis. The  pathological  changes  in  the  mucous  mem- 
brane are  similar  to  those  of  catarrh  in  other  portions 
of  the  body.  When  the  tube  becomes  dilated,  the  folds 
of  mucous  membrane  are  lost ;  the  membrane  is  some- 
times thickened ;  its  inner  surface  may  have  an  appear- 
ance somewhat  like  serous  membrane  covered  with 
granular  or  calcareous  concretions.  The  muscular  walls 
undergo  partial  atrophy,  and  occasionally  are  ecchy- 
mosed. 

Acute  salpingitis  is  not  susceptible  of  diagnosis  as 
such,  apart  from  pelvic  peritonitis  and  cellulitis,  and 
therefore  will  not  be  considered.  The  symptoms  of 
chronic  salpingitis  and  dilatation  of  the  tube  are  the 
same  as  those  of  inflammation  of  the  adjoining  struc- 
tures. A  history  of  chronic  pelvic  peritonitis  or  cellu- 
litis with  intermissions  of  comparative  health  for  a  few 
weeks  or  months,  and  the  occasional  outbursts  of  in- 
flammation without  any  apparent  or  definite  cause,  point 
to  the  presence  of  chronic  salpingitis. 

The  Diagnosis  is  difficult.  In  favorable  cases,  when 
the  abdominal  walls  are  thin  and  relaxed,  the  distended 
tube  may  be  felt  by  careful  bi-manual  examination ; 
but  the  most  experienced  examiner  cannot  always 
detect  the  enlarged  tube  without  an  abdominal  in- 
cision, even  when  the  patient  is  under  the  influence  of 
ether  to  secure  greater  muscular  relaxation.  Schatz's 
chair  is  very  useful  in  examining  the  tubes  and  ovaries, 


356      DISEASES  OF  THE  FALLOPIAN  TUBES. 

as  the  patient  is  compelled  to  take  a  position  which 
thoroughly  relaxes  the  abdominal  wall,  and  makes  a 
bi-manual  examination  very  much  easier.  The  tumor 
extends  from  either  horn  of  the  uterus,  and  is  felt  as 
a  thickening  along  the  broad  ligament,  or  as  a  sausage- 
shaped  mass  about  the  size  of  the  finger.  When 
removed,  it  is  about  three  inches  long  with  numerous 
constrictions,  and  similar  in  appearance  to  a  small 
section  of  distended  intestine.  Sterility  commonly  at- 
tends this  disease  when  both  tubes  are  affected. 

The  Treatment  is  the  same  as  for  pelvic  peritonitis 
and  cellulitis.  If  the  case  continues  obstinate  after  a 
faithful  trial  of  some  months,  it  may  become  necessary 
to  remove  the  tubes  and  ovaries  (Tait's  operation). 
The  writer  feels  that  this  operation,  so  popular  with 
some  gynaecologists,  is  not  entirely  devoid  of  danger, 
unsexes  the  woman,  and  is  not  infrequently  performed 
when  a  careful  study  of  the  materia  medica  and  faithful 
treatment  of  the  case  would  have  cured  it. 

I  am  not  acquainted  with  remedies  having  a  specific 
relation  to  this  disease  apart  from  endometritis,  pelvic 
cellulitis,  and  peritonitis.  The  reader  is  therefore  re- 
ferred to  the  chapters  on  those  subjects.  Dr.  C.  Hen- 
nig  has  recorded  a  cases  of  phosphorus  poisoning  which 
seemed  to  cause  catarrhal  salpingitis.  Acting  on  this 
hint,  phosphorus  may  prove  a  useful  remedy. 


OVARIAN  NEURALGTA.  357 


CHAPTER    XXV. 

OVARIAN      NEURALGIA. 

THIS  very  painful  affection  is  due  to  the  same  causes 
which  produce  neuralgia  in  other  parts  of  the  body. 
Dr.  F.  E.  Anstie,  in  his  well-known  work  on  Neuralgia, 
makes  this  remark  in  regard  to  uterine  and  ovarian 
neuralgias  :  "  In  one  aspect,  the  affections  possess  a 
special  interest  ;  namely,  this,  that  they  are  more  fre- 
quently dependent  on  peripheral  irritation  for  their 
immediate  causation  than  any  other  group  of  neural- 
gias." The  causes  are  numerous,  and  may  be  described 
as  follows  :  — 

The  neuralgic,  rheumatic,  or  hysterical  diathesis. 

Poor  state  of  health. 

Ascarides  in  the  rectum. 

Profuse  and  intractable  leucorrhoea. 

Calculus  in  the  kidney  or  ureter. 

Prolapsus  uteri. 

Presence  of  tumors,  cancerous  or  fibroids. 

Severe  erosion  and  laceration  of  the  cervix  uteri. 

Impaction  of  faeces. 

Reflex  irritation  from  distant  parts  of  the  body. 

Excessive  or  incomplete  sexual  intercourse. 

Ungratified  sexual  desire. 

This  is  a  formidable  list,  the  first  two  and  the  last 
three  of  which  are  by  far  the  most  important. 


358  OVARIAN  NEURALGIA. 

The  attack  comes  suddenly  without  any  warning  ;  the 
pain,  while  more  severe  than  in  ovaritis,  varies  in  inten- 
sity and  locality  in  different  subjects,  not  infrequently 
remits,  and  gradually  passes  away.  It  is  usually  in  one 
ovary,  extending  down  the  thigh,  fixed  in  one  spot,  or 
radiating  from  it  up  into  the  abdomen.  It  is  of  an 
intense  lancinating  or  cramp-like  character,  and  not 
infrequently  attended  with  vomiting,  fainting,  hysterical 
spasms,  and  doubling-up  of  the  body  on  the  affected 
side,  which  is  exceedingly  sensitive  to  the  slightest 
touch. 

It  is  distinguished  from  abdommal  colic,  ovaritis,  and 
peritonitis,  by  its  location  in  the  ovarian  region,  the  his- 
tory of  previous  attacks,  the  sudden  occurrence,  severity 
of  the  pain,  absence  of  chill  or  rise  in  temperature,  and 
its  proneness  to  affect  neuralgic  or  hysterical  women. 

Pros^nosis.  —  No  one  ever  dies  as  the  direct  result  of 
ovarian  neuralgia.  On  the  other  hand,  it  is  a  difficult 
affection  to  cure,  unless  the  exciting  cause  can  be  re- 
moved. 

General  Treatment.  —  The  first  object  is  to  build  the 
patient  up  to  the  maximum  of  health.  Out-door  air, 
exercise,  good  food  and  plenty  of  it,  pleasant  surround- 
ings, mental  rest,  freedom  from  care,  and  regulation  of 
sexual  matters,  are  all  important.  Marriage  and  child- 
bearing  are  often  beneficial.  It  is  hardly  necessary  to 
say  that  the  cause  must  be  carefully  sought  out  and 
removed  if  possible.  Flannel  underwear  should  be  worn  ; 
and,  in  addition,  a  pad  of  uncarded  wool,  basted  to  the 
underclothing  over  the  hypogastrium,  will  act  as  a  pre- 
ventive in  protecting  that  region  from  cold.  Closed 
drawers  are  better  than  open  ones  for  the  same  reason  ; 
and  the  feet  must  be  kept  warm  and  dry  by  thick  shoes 
and  stockings. 

At  the  time  of  the  attack,  heat,  in  the  shape  of  hot 


THERAPEUTICS.  359 

flannels,  a  hot  hop  or  bran  bag,  may  palliate  the  pain. 
Counter-irritation,  in  the  form  of  a  mild  mustard- 
plaster,  or  camphor  and  turpentine,  applied  over  the 
seat  of  pain,  sometimes  relieves.  Besides  this,  a  vaginal 
injection  can  be  used  of  hot  water,  glycerine,  and  the 
watery  extract  of  hamamelis,  in  equal  parts  ;  or,  instead 
of  the  latter,  the  strong  tincture  of  aconite,  —  prefer- 
ably the  aconitum  uncinatum,  —  in  the  proportion  of 
about  ten  per  cent.  Some  prefer  to  apply  the  aconite, 
either  alone  or  mixed  with  an  equal  quantity  of  chloro- 
form, on  the  skin  over  the  site  of  pain.  If  the  rectum 
be  loaded  with  faecal  matter,  no  time  should  be  lost  in 
giving  an  enema,  and  removing  a  possible  cause  of  the 
pain. 

Medical  Treatment.  —  In  the  intervals  between  the 
attacks,  constitutional  remedies  are  necessary  to  dispel 
the  tendency  to  recurrence.  It  is  of  little  use  to  give 
them  unless  the  physician's  directions  will  be  strictly 
and  perseveringly  observed.  Chronic  cases  may  re- 
quire months  of  faithful  treatment. 

THERAPEUTICS. 

Ammonium  mur.  Suited  to  fleshy  women  and  mild 
cases  ;  cutting,  stitching  pains  from  pubes  to  small  of  back,  with 
urging  to  urinate  ;  griping  pain  about  the  navel ;  constipation  ; 
hard,  crumbling  stools. 

Arsenicum.  Violent  burning  pain  in  the  abdomen,  with 
great  anguish,  rolling  and  tossing  about;  abdomen  distended 
and  painful ;  drawing,  stitching,  burning,  or  tensive  pain  in 
the  ovaries,  the  right  rather  than  the  left. 

I  Atropine.'     The  same  symptoms  as  those  which  would 

'  Mrs.  W.  W.,  confined  three  months  ago  ;  lochial  discharge  ceased  suddettly 
a  fortnight  after  confinement;  since  that  time  suffered  intense  agony,  with  inter- 
mittent neuralgia  of  the  right  ovary;  violent  clawing,  griping  pains,  causing 
constant  exclamations,  for  twenty-four  hours  at  a  time  without  interruption  ;  at 
lengtli  the  pains  ceased  entirely,  but  invariably  returned  with  new  vigor ;   much 


36o  OVARIAN  NEURALGIA. 

call  for  belladonna ;  intense  clawing,  clutching,  pain  in  the  uterine 
region,  with  great  sensitiveness  to  touch,  and  bearing-down 
sensations  ;  face  flushed,  pupils  dilated,  sometimes  delirious. 

I  Colocynth.  Intense  pain  in  the  inguinal  region  ;  boring, 
tensive  pain  in  the  ovary,  more  especially  the  left  one ;  patient 
is  doubled  up  with  pain,  and  seeks  relief  by  pressing  the  abdo- 
men against  something  hard,  as  a  table,  chair,  or  bedpost ;  pain 
may  concentrate  in  the  pit  of  the  stomacl,i,  with  eructations, 
nausea,  or  vomiting.  Attacks  caused  by  vexation,  or  eating 
potatoes. 

Macrotin.  A  good  remedy  when  the  attack  seems  due  to 
a  metastasis  of  rheumatism  in  nervous  women  at  the  climacteric. 
The  patient  is  irritable,  melancholic,  and  subject  to  infra- 
mammary  pains  in  the  left  side. 

Naja  has  proved  very  serviceable  for  violent,  cramp-like 
pain  in  the  region  of  the  left  ovary,  with  violent  palpitation 
of  the  heart.  Dr.  Hughes  states  that  "  it  has  become  my  own 
favorite  medicine  for  obscure  ovarian  pain,  not  frankly  inflam- 
matory." 

Xanthoxylon.  Violent  pains  in  the  loins  and  lower  part 
of  the  abdomen,  and  especially  in  the  left  side,  which  extend 
through  the  iiiternal  abdominal  ring,  and  down  on  the  inner 
anterior  surface  of  the  thigh.  The  writer  knows  of  one  case, 
characterized  by  these  symptoms,  which  was  promptly  cured  by 
this  remedy.  Her  agony  was  so  great  that  she  could  hardly  be 
held  on  the  bed,  making  it  necessary  to  keep  her  partially  under 
the  influence  of  ether  for  some  hours,  till  this  remedy  was  given 
with  remarkable  effect. 

II  Valerianate  of  Zinc.  Chronic  ovaralgia  in  hysterical 
women.  It  is  also  useful  as  a  constitutional  remedy  to  break 
up  the  tendency  to  the  attacks.  Useful  as  this  remedy  is  for 
various  kinds  of  neuralgias,  the  indications  for  it  have  not  yet 
been  precisely  defined. 

thirst  and  vomiting  during  the  pain,  which  occurred  day  or  night ;  for  two  months 
and  a  half  took  much  laxative  and  other  medicine,  as  well  as  opium  in  abundance. 
Prescribed  bell.  2C.  in  water,  a  teaspoonful  every  two  hours ;  cured  in  about  one 
week  ;  has  remained  well  since,  now  two  years.  —  Dr.  C.  Wesselhoeft  :  Am, 
y.  of  Horn.  Mat.  Med.,  p.  22,  vol.  iv.,  1870. 


THERAPEUTICS.  3^1 

For  further  constiltatioit  see  aconite,'  ammon.  nuir.,^ 
cham.,  chin.,  sulph.,  coffea,  cupr-um,  gels.,  hyosc,  igna- 
tia,3  mag.  phos.,  mere.  cor. 

For  constitutional  remedies  consult  arg.  nit,  ars.,  calc. 
carb.,  ferr.  et  strych.,  graphites,  nat.  mur.,  sulphur,  zinc. 

•  The  aconitum  uncinatum  has  been  found  very  useful  for  neuralgias. 
^  Dr.  Searle  says  it  is  almost  a  specific  in  the  crude  form. 
3  This  cured  a  case  of  almost  daily  ovaralgia  with  great  nervousness  -during 
pregnancy. 


362  DISEASES  OF  THE   OVARIES. 


CHAPTER   XXVI. 

DISEASES    OF    THE    OVARIES. 

UNDER  very  favorable  conditions,  such  as  thin,  re- 
laxed abdominal  walls,  elastic  perineum,  and  flexion 
of  the  thighs  on  the  body  with  outward  rotation  of  the 
knees,  the  normal  ovaries  can  sometimes  be  felt  by  an 
experienced  examiner.  The  psoas  muscles  are  made 
tense,  so  that  their  inner  margins  are  more  easily  pal- 
pable, by  rotating  the  knees  outward.  According  to 
Schultze,  these  form  a  guide  to  the  normal  position  of 
the  ovaries,  which  is  about  on  a  level  with  the  brim 
of  the  pelvis,  midway  between  the  psoas  muscles  and 
the  insertion  of  the  Fallopian  tubes  into  the  uterus. 
The  ovaries  enlarge  at  the  menstrual  epochs,  but  in  a 
general  way  can  be  described  as  two  oval-shaped  bodies, 
each  somewhat  larger  than  a  chestnut,  and  possessing 
great  mobility.  The  larger  the  ovary  and  the  lower  it 
is  down  in  the  pelvis,  the  more  easily  it  is  felt.  In 
examining  them,  the  patient  must  occupy  the  dorsal 
position,  with  the  thighs  flexed,  and  knees  well  rotated 
outward.  If  the  physician  desires  to  examine  the  right 
ovary,  he  must  use  his  right  forefinger,  and  if  that  is 
not  enough,  the  middle  one  also  ;  if  the  left  ovary,  his 
left  hand ;  and  always  the  other  hand  over  the  abdomen 
as  in  a  bi-manual  examination. 

In  order  to  reach  well  up  in  the  pelvis,  he  will  mate- 
rially help  himself  by  supporting  his  elbow  against  his 
hips   or   body,  and  crowding  firmly  backward  and  up- 


PALPATION  OF   THE   OVARIES.  363 

ward  on  the  perineum  with  the  side  and  base  of  his 
finger,  while  at  the  same  time  he  presses  down  from 
above,  and  engages  the  patient  in  conversation  to  pre- 
vent her  from  stiffening  the  abdominal  muscles  if 
ether  be  not  used. 

Another  method  of  examining  the  ovaries  is  to  give  an 
anaesthetic,  draw  down  the  uterus  with  volsellum  forceps, 
and  make  an  examination  of  the  ovaries  per  rectum. 
This  should  never  be  attempted  where  there  are  adhe- 
sions in  the  pelvis ;  inflammation  of  the  uterus,  cellular 
tissue,  or  ligaments,  however  slight ;  varicose  veins  or 
long-standing  hemorrhoids  :  the  presence  of  the  first 
two  would  be  liable  to  cause  severe  inflammation  of  the 
pelvic  organs,  and  of  the  latter,  pelvic  haematocele. 

The  affections  of  the  ovaries  can  be  enumerated  as 
apoplexy  g»r  haematoma,  presence  of  a  third  ovary, 
absence,  imperfect  development,  displacement,'  inflam- 
mation or  ovaritis,  and  tumors  of  the  ovary. 

The  symptoms  of  ovarian  apoplexy  or  haematoma 
are  those  of  pelvic  haematocele  ;  and  the  diagnosis  is 
made  by  the  presence  of  a  sudden  enlargement  of  the 
ovary  with  such  symptoms.  It  is  very  rare,  treated  by 
letting  it  alone,  and  of  little  if  any  practical  impor- 
tance. The  presence  of  a  third  ovary  is  extremely  rare, 
and  only  interesting  as  possibly  serving  to  explain  the 
occurrence  of  menstruation  after  the  removal  of  two 
ovaries. 

The  positive  diagnosis  of  the  absence  of  the  ovaries 
or  their  imperfect  development  is  impracticable.  The 
most  characteristic  symptom  is  amenorrhoea  with  little 
or  only  partial  growth  of  the  sexual  organs,  fiat  breasts, 
hairy  face,  coarse  voice,  masculine  appearance,  and, 
instead  of  developing  from  girlhood  into  womanhood, 
she  remains  physically  a  girl.     The  occasional  use  of  a 

'  See  chapter  on  Displacements  of  the  Sexual  Organs. 


364  DISEASES  OF  THE   OVARIES. 

tent  in  the  cervical  canal  and  the  galvanic  stem  pessary- 
have  been  used  with  benefit  in  a  few  cases.  Not  much 
encouragement,  however,  can  be  given  to  such  patients. 

l7iflaminatio7i  of  the  ovary,  ovaritis,  sometimes  called 
oophoritis,  may  affect  the  parenchyma  (follicular  por- 
tion) of  the  ovary  or  the  interstitial  (medullary)  part, 
and  be  either  acute  or  chronic.  Both  the  parenchyma- 
tous and  interstitial  forms  are  limited  to  the  menstrual 
life  of  a  woman,  and  neither  can  be  diagnosed  from  the 
other  in  the  living;  both  are  usually  present  at  the  same 
time,  though  the  one  may  preponderate  over  the  other. 
In  parenchymatous  ovaritis,  the  Graafian  follicles  are 
involved,  and  often  destroyed.  In  interstitial  ovaritis 
there  is  a  proliferation  of  connective-tissue  cells,  some 
enlargement  of  the  ovary,  with  subsequent  contraction 
and  atrophy,  which  also  destroys  the  follicles.  This 
process  is  not  unlike  cirrhosis  of  the  liver.  The  left 
ovary  is  much  more  often  affected  than  the  right,  both 
from  the  presence  of  a  loaded  rectum  on  that  side,  and 
from  the  greater  frequency  of  laceration  of  the  cervix 
uteri  on  the  same  side,  which  is  a  constant  source  of 
irritatioil.  When  both  ovaries  become  chronically  in- 
flamed, sterility  is  liable  to  follow  in  consequence  of 
ovarian  atrophy,  of  destruction  of  the  Graafian  follicles, 
of  the  thickening  of  the  outer  surface  of  the  ovary, 
or  of  the  adhesions  which  bind  the  uterus  down  or  con- 
strict the  Fallopian  tubes. 

A  more  practical  division  of  ovaritis,  from  a  clinical 
point  of  view,  is  into  the  acute  and  chronic  forms. 

Acute  Ovaritis  as  an  idiopathic  uncomplicated  affec- 
tion is  very  uncommon.  The  causes  are :  puerperal 
septicaemia,  sudden  suppression  of  the  menses,  exten- 
sion of  inflammation  from  the  uterus  or  peritoneum, 
gonorrhoea,  cold-water  or  astringent  injections,  excessive 
venery,  the  production  of  abortion,  acute  exanthematic 


ACUTE  AND   CHRONIC  OVARITIS.  365 

diseases,  and  the  improper  use  of  the  sound  or  other 
instruments. 

It  may  seem  strange  to  speak  of  uncomplicated  ova- 
ritis as  a  very  uncommon  affection  with  such  an  array 
of  causes  ;  but  these  also  produce  inflammation  of  the 
structures  surrounding  the  ovary,  and  the  symptoms  of 
ovaritis  are  so  often  kept  in  the  background  or  masked 
by  the  accompanying  pelvic  peritonitis,  that  a  differen- 
tiation of  the  symptoms  is  practically  impossible  in 
most  cases.  In  other  words,  the  symptoms  of  acute 
ovaritis  are  those  of  pelvic  peritonitis  localized  in  the 
ovarian  region,  with  pains  radiating  to  the  side  and 
back,  sometimes  tumefaction,  and  flexion  of  the  thigh  to 
relieve  the  tension  on  this  exquisitely  sensitive  region. 

On  bi-manual  examination,  the  ovaries  are  found 
slightly  enlarged  ;  tender  and  slight  pressure  causes  a 
sickening  pain  similar  to  that  caused  by  pressure  on 
the  testis. 

The  interstitial  variety  has  been  known  to  terminate 
in  abscess  of  the  ovary  ;  but  this  is  extremely  rare  out- 
side of  puerperal  septicaemia,  and  is  seldom  observed 
in  it.  The  symptoms  and  treatment  are  the  same  as  for 
pelvic  abscess,  but  there  is  more  danger  from  its  greater 
liability  to  break  into  the  peritoneal  cavity. 

Chronic  Ovaritis,  besides  resulting  from  the  acute 
form  and  its  causes,  has  been  produced  by  phosphorus 
and  arsenic  poisoning,  displacement  of  the  pelvic 
organs  causing  irregular  circulation,  cauterization  of 
the  cervix  with  nitrate  of  silver,  and  apparently  by  the 
metastasis  of  rheumatism.  The  latter  should  warn  us 
to  be  careful  in  using  local  applications  for  the  treat- 
ment of  rheumatism  in  women  subject  to  ovarian  dis- 
order. Chronic  ovaritis  is  a  common  affection,  some- 
times bi-lateral,  but  most  frequent  on  the  left  side  for 
reasons  previously  stated. 


366  DISEASES  OF  THE   OVARIES. 

The  Symptoms  vary  much  in  different  cases.  One  of 
the  most  marked  is  the  presence  of  pain  in  the  ovarian 
region,  of  a  dull  aching  or  burning  character,  aggravated 
by  walking.  This,  however,  does  not  prove  that  ovarian 
inflammation  is  present,  as  the  same  pain  is  very  char- 
acteristic of  disease  of  the  neck  of  the  uterus  inde- 
pendent of  any  ovaritis.  Neither  does  tenderness  on 
pressure  in  the  lateral  hypogastric  or  supra-inguinal 
region  necessarily  mean  ovaritis,  though  it  often  accom- 
panies it.  Dr.  Graily  Hewitt  holds  that  this  tenderness 
is  most  often  due  to  anteversion  of  the  uterus.  Men- 
strual irregularities  are  quite  frequent,  especially  dys- 
menorrhoea  and  menorrhagia.  There  are  sometimes 
hysterical  manifestations  ;  infra-mammary  pain  at  the 
menstrual  epochs,  more  often  in  the  left  side ;  painful 
defecation ;  dyspareunia ;  and  a  very  intractable  form 
of  uterine  catarrh  due  to  the  long-continued  irritation. 
One  great  characteristic  of  all  the  symptoms  is  their 
aggravation  at  the  menstrual  epoch. 

The  Diagnosis  is  made  by  the  preceding  symptoms 
and  finding,  by  bi-manual  examination  through  the 
vagina  or  rectum,  the  extremely  sensitive  ovaries,  which 
are  often  a  little  enlarged  or  prolapsed. 

TJie  Prognosis  is  uncertain,  but  usually  unfavorable 
if  absolute  sexual  continence,  and  rest  during  the  men- 
strual period,  be  not  faithfully  observed.  The  physician 
should  also  be  wary  in  promising  a  cure  when  the 
ovaritis  has  been  caused  by  cauterizing  the  cervix  with 
nitrate  of  silver.  In  some  instances,  the  writer  has 
been  surprised  at  the  favorable  results  obtained  in  cases 
of  long  standing.  Treatment  must  be  persevering  to 
be  effectual,  and  almost  every  thing  depends  on  the 
correct  selection  of  the  remedy. 

General  and  Local  Treatment.  —  Four  things  are 
essential  in  the  treatment  of  ovaritis,  —  a  generous  diet 


TREATMENT  OF  OVARITIS.  367 

of  nutritious  food  to  maintain  a  high  standard  of  health  ; 
avoidance  of  all  exercise  which  increases  the  pain  ;  rest 
in  bed  during  the  menstrual  period;  and,  most  impor- 
tant of  all,  there  must  be  no  sexual  indulgence  or 
excitation.  Chronic  constipation  must  be  removed 
if  possible,  as  this  favors  sluggish  portal  circulation, 
which  increases  the  venous  congestion  of  the  pelvic 
organs. 

The  use  of  a  hot  hop-bag,  dry  hot  bran-bag,  com- 
presses of  hamamelis,  wormwood,  and  alcohol,  or  cam- 
phor and  turpentine,,,  and  the  inunction  of  belladonna 
cerate  externally  have  been  recommended  for  the  pain 
in  acute  attacks  ;  also,  small  mustard-plasters,  painting 
with  iodine,  and  the  application  of  leeches.  Some 
relief  may  be  obtained  by  these  measures,  but  their 
chief  use  is  apparently  to  make  a  show  of  doing  some- 
thing for  the  patient.  On  the  other  hand,  much  relief 
has  been  given  by  copious  hot  vaginal  douches,  to  the 
last  half-pint  of  which  have  been  added  three  tablespoon- 
fuls  of  a  strong  extract  of  hamamelis  (Pond's  extract  of 
witch-hazel),  and  the  same  amount  of  glycerine.  It 
should  be  given  for  at  least  twenty  minutes,  night  and 
morning,  till  all  signs  of  inflammation  have  disappeared. 
Iodine  is  of  little  use  here,  except  for  the  complications 
of  pelvic  peritonitis  and  cellulitis.  Rectal  injections 
have  been  favorably  mentioned  for  left-sided  ovaritis, 
but  the  author  sees  little,  if  any,  advantage  in  them 
over  the  vaginal  douche.  The  use  of  opium  in  any 
form  is  to  be  scrupulously  avoided  if  possible.  It  is 
only  palliative  at  best,  and  the  mental  condition  of  the 
patient  is  such  that  she  is  peculiarly  prone  to  acquire 
the  opium-habit. 

In  very  severe  cases  which  are  not  amenable  to  long- 
continued  and  faithful  treatment,  the  ovaries  can  be 
removed  by  Battey's,  Hegar's,  or  Tait's  operation. 


368  DISEASES  OF  THE   OVARIES. 

This  operation,  known  as  castration/  has  also  been 
recommended  for  the  relief  of  nervous  and  mental  dis- 
eases. Schroeder^  believed  it  was  best  to  remove  even 
perfectly  healthy  ovaries  for  the  relief  of  neuroses, 
and  reports  some  severe  cases  cured  by  the  operation. 
According  to  his  experience,  the  best  results  are  ob- 
tained in  those  cases  in  which  the  menses  appeared  at 
a  very  early  age,  —  in  two  cases  in  the  ninth  year, — 
and  when  sexual  conditions  play  a  great  role  in  the  eti- 
ology of  the  neuroses.  Most  observers,  however,  agree 
that  healthy  ovaries  should  not  be  removed  for  disorders 
of  the  nervous  system.^  Prochownilc*  of  Hamburg 
found  the  results  were  not  so  good  when  healthy 
ovaries  or  those  but  little  diseased  were  removed  for 
neuroses  complicating  sexual  disorders. 

Medical  Treatment.  —  In  selecting  a  remedy,  the 
symptoms  of  the  menstrual  flow  must  be  considered 
with  the  ovarian  pains.  In  chronic  cases,  a  carefully 
chosen  remedy  ought  to  be  given  at  least  a  fortnight 
or  longer  without  changing  it,  as  immediate  effects  are 
seldom  seen.  Some  cases  recover  much  sooner ;  but, 
as  a  rule,  the  acute  ones  require  from  six  weeks  to  two 
months,  and  the  chronic,  six  to  eight  months. 

*  The  definition  of  castration  was  discussed  at  the  meeting  of  the  Gesellschaft 
fiir  Geburtshiilfe  und  Gynakologie  in  Berlin,  June  ii  and  24,  1S87.  Many  believe 
castration  should  apply  to  the  removal  of  healthy  ovaries  only,  and  ovariotomy  to 
the  removal  of  diseased  ovaries.  Hegar  has  given  an  excellent  resume  of  the 
subject,  shown  the  fallacies  of  the  above  definitions,  and  advocates  its  application 
to  the  removal  of  both  diseased  and  healthy  ovaries.  His  article  will  be  found  in 
the  Centralblatt  fiir  Gynakologie,  No.  44,  Oct.  29,  1887. 

^  Ueber  die  Kastration  bei  Neurosen.  Zeitschrift  fiir  Geburtshiilfe  und  Gyna- 
kologie, Bd.  xiii.  Hft.  2. 

3  The  opinions  of  Spencer  Wells,  Alfred  Hegar,  and  Robert  Battey  can  be 
found  in  the  American  Journal  of  the  Medical  Sciences,  p.  455,  October,  1886. 

*  Beitrage  zur  Kastrationsfrage.     Archiv  fiir  Gynakologie,  Bd.  xxix.  Heft.  2. 


THERAPEUTICS  OF  OVARITIS.  369 


THERAPEUTICS. 

Aconite  has  been  considered  a  good  remedy  for  puerperal 
ovaritis  in  alternation  with  arnica,  if  there  has  been  much  trau- 
matism. It  is  useful  for  acute  ovaritis  with  painful  urging  to 
urinate,  high  fever,  and  when  it  follows  sudden  suppression  of 
the  menstrual  flow  (Apis,  bell.,  cimicif.,  puis.).  Some  physi- 
cians alternate  it  with  bryonia.  Generally  speaking,  aconite  is 
inferior  to  belladonna,  which  has  a  more  specific  action  on  the 
ovaries,  and  should  be  used  if  aconite  doe?  not  soon  relieve 
the  pain  and  fever. 

II  Apis.  Either  acute  or  chronic  ovaritis,  especially  in  the 
right  side,  and  when  it  is  associated  with  an  exudation  into 
the  peritoneum  or  cellular  tissue.  The  symptoms  calling  for  it 
are  :  enlargement  of  the  right  ovary  (Bell.),  with  pain  in  the 
left  side  of  the  chest,  and  cough ;  burning,  stinging  pains  in 
the  ovaries,  worse  at  time  of  menses ;  tenderness  of  hypogas- 
triura ;  urging  to  urinate ;  ovaritis  with  suppression  of  the 
menses   (Aeon.,  bell.,  cimicif.,  puis.). 

Arsenicum.  Burning,  tensive,  stitching,  pressive  pains  in 
the  ovaries,  especially  the  right,  sometimes  extending  into  the 
thigh,  making  it  feel  numb  and  lame,  worse  from  motion  and 
sitting  bent ;  corrosive  leucorrhoea ;  backache ;  the  pain  is  re- 
lieved by  the  application  of  heat ;  the  patient  is  thirsty,  very 
irritable,  and  restless. 

II  Belladonna.  The  chief  remedy  for  the  treatment  of 
acute  ovaritis,  and  also  useful  for  the  chronic  form  ;  but  imme- 
diate results  in  the  latter  will  not  be  obtained.  It  is  very  valu- 
able when  the  peritoneum  is  involved  (Bry.,  coloc,  mere,  cor.), 
either  with  the  puerperal  state  or  independent  of  it.  The 
symptoms  appear  suddenly  with  marked  signs  of  local  conges- 
tion ;  severe  pain  of  a  clutching,  clawing,  stabbing,  or  throbbing 
character  in  the  ovarian  region,  especially  the  right,  with  great 
local  sensitiveness  ;  cannot  bear  the  least  jar ;  painful  bearing- 
down  ;  high  fever ;  thirst ;  flushed  face,  and  even  delirium  in 
post-partum  cases ;  lochia  feels  hot  to  the  patient.  It  is  also 
useful  for  mild  cases,  worse  during  the  menstrual  periods. 


370  DISEASES   OF   THE    OVARIES. 

I  Bryonia  was  a  favorite  remedy  with  Drs.  Jahr  and  Leadam  ; 
but  Dr.  Ludlam  does  not  express  a  favorable  opinion  of  it, 
except  where  the  ovaritis  seems  to  be  rheumatic  in  origin 
(Macrotin,  rhododendron,  rhus  tox.) .  It  seems  to  be  best  suited 
to  cases  of  moderate  severity,  with  stitching  pains,  worse  on 
coughing,  inspiration  (Canth.),  and  motion;  pain  shooting  or 
extending  to  the  hips  (Merc). 

Cantharis.  Patient  cannot  breathe  freely  on  account  of 
the  stitching,  pinching  pains  in  the  ovarian  region  (Bry.)  ;  cut- 
ting, burning  pains  in  the  ovaries  ;  bearing-down  in  the  genitals  ; 
violent  pains  in  the  bladdei',  with  frequent  urging  and  great 
tenesmus  (Terebinthina)  ;  excitement  of  the  sexual  instinct 
(Platina,  sabina). 

I  Colocynth.  Ovaritis,  the  left  rather  than  the  right  side, 
complicated  with  peritonitis,  especially  when  it  follows  an  abor- 
tion ;  numbness  in  the  limbs  (Plat.)  ;  cramp-like  or  boring  ten- 
sive pain  in  the  ovaries,  causing  the  patient  to  double  up,  with 
great  restlessness ;  pain  extends  down  the  inner  side  of  the 
thigh  (Phos.,  staph.,  xanthox.).  There  is  much  pain  in  the  ab- 
domen, and  sometimes  diarrhoea  and  tenesmus  of  the  bladder 
(Canth.).  The  ovaritis  calling  for  colocynth  is  characterized 
by  the  severe  colicky  pains  in  the  left  ovary. 

Conium.  Chronic  ovaritis ;  induration  and  enlargement 
of  the  ovaries,  with  lancinating  pains  ;  soreness  and  swelling  of 
the  breasts  before  the  menses ;  menses  feeble  or  absent ;  leu- 
corrhoea  thick,  milky,  with  labor-like  pain,  or  of  white  acrid 
mucus,  causing  burning ;  offensive  eructations,  vomiting,  sour 
rising,  or  violent  pain  in  the  stomach. 

■  Hamamelis.  Gonorrhoea!  ovaritis ;  sub-acute  ovaritis, 
or  ovaritis  without  peritoneal  complications  (Puis.)  ;  ovaries  are 
sore  and  painful,  soreness  over  the  abdomen  ;  menses  irregular 
or  profuse,  with  dysmenorrhoea  and  varicose  veins. 

I  Lachesis.'  Drs.  Hughes  and  Guernsey  think  that  lachesis 
acts  more  on  the  right  ovary  than  on  the  left,  while  Drs.  Hering 
and  Lippe  give  the  left  ovary  the  preference.     Dr.  Hughes  thinks 

'  Amer.  Jouin.  of  Horn.  Mat.  Med.,  vol.  i.  p.  44  ;  and  U.  S.  Med.  and  Surg. 
Journ.,  vol.  ii.  p.  85. 


THERAPEUTICS   OE   OVA  RET  IS.  3/1 

naja,  an  analogous  remedy,  acts  more  on  the  left  ovary.  At 
Dr.  Hering's  suggestion,  lachesis  has  been  used  with  much 
benefit  for  chronic  enlargement  with  abscess  or  induration  of 
the  ovaries  ;  it  is  also  excellent  for  chronic  or  sub-acute  ovaritis, 
complicated  by  metritis,  especially  if  it  occurs  at  the  climacteric. 
Menses  feeble  and  scanty,  but  regular ;  labor-like  pains  before 
or  during  the  flow  {Caul.,  cimicif.,  puis.)  ;  cutting  uterine 
or  ovarian  pains  relieved  by  flow  of  blood  ;  copious,  greenish 
leucorrhoea,  which  causes  smarting ;  great  sensitiveness  of  the 
hypogastrium  ;  platina  follows  lachesis  well. 

Macrotin  is  preferred  by  some  to  cimicifuga  in  ovarian  dis- 
order ;  ovaritis  which  seems  to  be  due  to  a  metastasis  of  rheu- 
matism (Bry.,  rhododendron,  rhus).  The  pains  shoot  up  to 
the  side  (Puis.)  ;  the  hypogastrium  is  very  sensitive  to  press- 
ure, with  a  bearing-down  sensation  ;  the  menses  are  in-egular, 
delayed,  or  suppressed ;  great  nervousness  or  chorea  at  time 
of  the  menses;  infra-mammary  pains,  worse  on  the  left  side. 

I  Mercurius.  Dr.  Hughes  prefers  the  corrosivus,  and  Dr. 
Ludlam  the  vivus.  This  is  one  of  the  most  important  remedies, 
to  say  the  least,  for  ovaritis  complicated  with  peritonitis,  espe- 
cially in  the  puerperal  state,  to  avert  the  formation  of  an  abscess. 
There  is  deep  sore  pain  in  the  pelvis  (Ustilago,  podo.),  dragging 
in  the  loins,  sensation  of  weakness  in  the  abdomen  ;  or,  the 
abdomen  may  be  distended  and  painful,  with  a  bruised  sensa- 
tion, or  cutting,  stinging  pains,  worse  at  night ;  frequent  urging 
to  urinate  ;  perspiration  without  relief;  ovarian  pains  shoot  or 
extend  toward  the  hips  (Bry.). 

I  Platina.'  Sexual  desire  excited  (Sabina,  canth.)  ;  ovaritis 
with  burning  pains  in  paroxysms ;  numbness  in  the  limbs 
(Coloc.)  ;    menses  too  early  and  profuse  (Puis,  the  reverse). 


'  Mrs. .  Chronic  ovaritis  and  sterility.  Since  marriage,  twelve  years  pre- 
vious, she  has  had  pain  in  the  region  of  tlie  left  ovary,  and  a  feeling  of  internal 
soreness,  increased  by  going  up  stairs  or  any  sudden  movement.  She  had  had  an 
erosion  of  the  cervix  which  had  been  successfully  treated  by  nitrate  of  silver  without 
relief  to  the  ovarian  pain.  Had  never  been  pregnant.  Platina  6x.  was  prescribed. 
The  symptoms  disappeared  in  six  months,  and  in  three  months  more  she  became 
pregnant.  —  J.  Harmar  Smith,   M.R.C.S.  ;   British  Joitrii.  of  Horn.,  p.   157, 

1867,  vol.  XXV. 


372  DISEASES   OF   THE   O  VARIES. 

flow  dark ;  leucorrhcea  only  in  the  daytime ;  hysteria  and 
melancholia.  Chronic  cases  when  there  is  reason  to  suspect 
induration  of  the  ovaries.  If  platina  seems  indicated,  but 
mental  symptoms  do  not  correspond,  and  it  fails  to  cure. 
Dr.  Hering  recommended  palladium.  The  latter  seems  to  act 
best  on  ovarian  affections  of  the  right  side. 

Podophyllum,'  which  is  often  overlooked,  is  an  excellent 
remedy  for  ovaritis.  It  is  best  suited  to  cases  of  moderate 
severity ;  pain  in  the  region  of  the  ovaries,  especially  the  right; 
bearing-down  pain,  particularly  during  stool ;  frequent,  painless, 
watery  diarrhoea  is  sometimes  present ;  restless  sleep,  especially 
in  the  fore-part  of  the  night  {Fhos.). 

Sepia  is  a  good  remedy  for  chronic  ovaritis,  but  the  indica- 
tions for  it  are  scanty,  and  pertain  to  uterine  rather  than  ovarian 
disease  ;  dull,  heavy  pains  in  the  ovaries  with  pain  in  the  uterus, 
and  sensation  of  much  bearing-down  in  all  the  pelvic  organs ; 
yellow,  milky,  excoriating  leucorrhcea,  worse  before  the  menses  ; 
urging  to  urinate,  with  turbid,  clay-colored,  or  reddish  sedi- 
ment ;  constipation,  and  sense  of  goneness  or  emptiness  in  the 
stomach  and  abdomen. 

I  Thuja  is  of  great  value  for  left-sided  ovaritis,  worse  at 
each  menstrual  epoch  ;  distressing  pain,  burning  when  walking 
or  riding,  obUging  the  patient  to  lie  down.  It  is  also  good  for 
chronic  ovaritis,  with  a  suspicion  of  venereal  taint.  There  is 
a  tendency  to  the  formation  of  seedy  pediculated  warts  on  the 

'  I  found  this  remedy  very  useful  in  the  following  case :  A  young  woman  had 
caught  cold  four  months  previous  by  wetting  her  feet.  She  had,  nearly  eveiy  day, 
excruciating  attacks  of  pain  in  the  right  ovarian  region.  Examination  showed  a 
right-sided  ovaritis,  complicated  by  localized  pelvic  peritonitis  and  some  cellulitis  in 
the  same  side.  Benefit  was  derived  from  hot-water  douches,  glycerine,  and  hama- 
melis  locally,  as  well  as  bell.,  cimicif.,  and  arsenicum  at  different  times,  internally. 
The  paroxysms  of  pain  subsided,  leaving  a  deep-seated  aching  pain  in  the  right 
ovarian  region  which  ustilago  relieved,  but  only  for  a  short  time.  For  a  number  of 
years  she  had  not  been  able  to  go  to  sleep  till  nearly  morning  when  her  husband 
was  away,  but  slept  well  if  he  was  at  home.  At  this  time  she  caught  more  cold, 
and  suffered  agonizing  pain  for  nearly  twelve  hours.  This  ceased,  leaving  the 
same  deep-seated  pain,  only  worse,  and  increased  sensitiveness  in  the  right  ovarian 
region.  Podophyllum  yx..  gave  marked  relief  in  a  few  hours.  The  same  remedy 
was  continued  for  about  a  month  till  she  entirely  recovered,  and  could  sleep  sound 
all  night  independent  of  her  husband's  absence. 


DIGEST  OF  REMEDIES.  373 

skin,  persistent  sleeplessness,  morning  diarrhfx^a,  and  severe 
headache. 

Ustilago.  The  writer  has  found  this  remedy  useful  for 
deep-seated,  sore,  aching  pain  in  the  pelvis,  more  especially  the 
left  side ;  menses  scanty,  with  ovarian  irritation;  bearing-down 
pain  ;  burning  distress  in  the  ovaries  ;  acute  pain,  worse  in  the 
left  ovary,  intermitting  or  shooting  down  the  legs. 

Zincumhasa  peculiar  symptom  not  often  found  in  ovaritis; 
boring  pain  in  the  left  ovarian  region,  better  from  pressure,  but 
entirely  relieved  only  during  the  menstrual  flow. 

The  following  list  of  remedies  is  given  for  further 
consultation  :  — 

Arg.  met.,  arnica,  aurum  mur.,  cactus,  cauloph.,  china, 
clematis,  ferrum  phos.,'  gelseminum,^  grapJLites,T>  hepar 
sulph.,  ignatia,  iodine,^  HI.  tig.,  naja,  natrura  mur.,'* 
palladium,  phosphorus,^  phos.  ac,  Pulsatilla,^  rhus  tox., 
sabadilla,  sabina,  secale,  staphisagria,-  sulphur,  veratrum 
vir.,  xanthoxylon. 

'  Mrs. .     Much  left-sided  sub-mammary  and  sacral  pain,  especially  before 

the  menses  ;  the  latter  are  worse  on  lying  down  ;  bloating  of  the  lower  part  of  the 
chest  and  stomach ;  much  headache  during  the  day ;  low-spirited  ;  feels  weak ; 
acute  pain  in  the  lower  part  of  the  baclc,  causing  her  to  fall  back  when  rising  in 
the  morning ;  constaiit  desire  to  pass  water  day  and  night,  worse  in  the  day- 
time, with  pain  over  the  left  ovary,  worse  on  pressure,  increased  by  urination. 
Ferrum  phos.  ix.  trit.  pro-nptly  cured  her.  —  Dr.  Robert  T.  Cooper:  On  the 
Action  of  Iron,  Brit.  J.  of  Horn.,  p.  412,  1874. 

^  Recommended  by  Dr.  John  Moore,  Monthly  Horn.  Review,  Nov.  i,  p.  671, 
1871. 

3  Mrs. ,  aged  51.     In  each  iliac  fossa  I  found  a  very  hard   round   tumor, 

about  the  size  of  an  orange,  extending  nearly  to  the  median  line,  the  right  a  little 
larger  than  the  left.  Both  were  slightly  movable,  sensitive  to  firm  pressure,  and  the 
pa'ient  complained  of  their  weight.  These  had  been  gradually  growing  for  some 
time.  Graphites  12c.,  night  and  morning,  was  given  on  account  of  the  analogy  of 
the  swollen  ovaries  to  enlarged  testicles,  which  this  remedy  has  cured.  The  medi- 
cine was  only  taken  at  intervals  during  the  next  seven  months,  on  account  of  bron- 
chitis and  rheumatism,  which  required  other  remedies.  The  next  four  months 
the  remedy  was  used  continuously,  and  the  tumors  entirely  disappeared  and  have 
not  returned.  —  Dr.  Dudgeon  :  British  J.  of  Horn.,  p.  183,  vol.  xxxi.,  1873. 

To  be  borne  in  mind  for  the  treatment  of  ovaritis  caused  by  the  application 
of  nitrate  of  silver. 


374  DISEASES   OF   THE   OVARIES. 

The"  following-  digest  may  serve  to  suggest  a  rem- 
edy :  — 

Acute  ovaritis. — -Aeon.,  apis,  ars.,  bell.,  bry.,  canth., 
coloc,  guiac.,'  ham.,  macrotin,  puis.,  sabina. 

Chronic  ovai'itis. — /^[/zj-,  ars.,  china,  conium,  graph., 
ham.,  ignatia,  lachesis,  mere,  cor.,  palladium,  platina, 
podo.,  puis.,  sepia,  sulph.,  staphisagria,  thuja. 

Right  ovary. — Apis,  ars.,  bell.,  bry.,  fern,  lach.,  pal- 
ladium, podophyllum. 

Left  ovary.  —  Arg.  met.,  colocynth,  lach.,  lye,  najd, 
stram.,  phos.,  thuja. 

Ovaritis  due  to  abortion  or  ptterperal  septiccemia.  — 
Aeon.,  arn.,  ars.,  bell.,  coloc,  ham.,  lach.,  mere,  cor.,  se- 
cale,  veratr.  vir. 

Ovaritis  due  to  sexual  excesses. — Bell.,  china,  ham., 
ignatia,  phos., ///C'i'.  acid,  plat.,  staph.,  sulphur. 

Ovaritis  due  to  a  venereal  taint.  —  Aur.  mur.,  bell., 
canth.,  clematis,  mere.  sol.  or  iod.,  kali  iod.,  nitric  ac, 
thuja. 

Chronic  ovarian  pains.  —  A'piz,  bell.,  conium,  lach., 
mere,  iiaja,  podo.,  plat.,  puis.,  thuja,  ustilago. 

Ovaritis  with  menstrual  derangement. — Apis,  canth., 
cauloph.,  lach.,  macrotin,  platina,  pulsatilla,  sabina,  se- 
cale,  sepia. 

Atrophy  and  indiiration  of  the  ovaries.  —  Baryta  mur., 
conium,  graphites,  iodine,  platina. 

'  An  old  remedy  and  a  favorite  prescription  of  Dr.  Dewees,  especially  for 
rheumatic  patients.  Dr.  M.  0.  Terry  reports  three  cases  of  long  standing,  char- 
acterized by  pain  in  the  left  ovary,  irregular  menstruation,  and  dysmenorrhoea, 
which  were  cured  by  guiac.  in  ten-grain  suppositories. — New  York  State  Soc. 
Tra7isac.,  18S3. 


TUMORS   OF   THE    OVARIES,   ETC.  375 


CHAPTER    XXVII. 

TUMORS  OF  THE  OVARIES  AND  BROAD  LIGAMENTS. 

VOLUMES  have  been  written  on  this  subject  alone, 
and  in  the  small  space  available  in  the  present 
work  theoretical  questions  cannot  be  discussed.  Great 
advances  have  been  made  in  the  treatment  of  these 
growths  ;  indeed,  it  may  be  called  the  triumph  of  sur- 
gery ;  but  there  is  very  little  known  of  their  origin,  and 
various  authors  differ  materially  in  describing  their 
pathological  details.  Neither  of  these,  fortunately,  is 
essential  to  their  diagnosis  and  treatment.  Interesting 
as  it  might  be  to  the  curious  reader,  etiology  and  the 
minute  details  of  pathology  must  be  omitted  to  give 
place  to  points  of  direct  practical  importance  to  the 
practitioner.' 

It  is  interesting  to  note,  however,  that  unmarried 
women  are  much  more  liable  to  ovarian  tumors  than  the 
married,  contrary  to  the  rule  for  fibroid  tumors.  Among 
1,686  patients,  66i  were  unmarried  and  1,025  married. 
In  a  series  reported  by  one  German  and  one  English 
surgeon,  737  women  were  married  and  508  unmarried. 
The  number  of  married  women  between  twenty  and 
fifty  years  of  age  is  very  much  larger  than  the  num- 
ber of  unmarried  of  the  same  age ;  in  Prussia  the  pro- 
portion of  married  women  is  five  times  as  great. 

'  For  further  study,  the  reader  is  referred,  in  order  of  preference,  to  the  works 
of  Sir  Spencer  Wells,  Greig  Smith,  R.  Olshausen,  Drs.  Peaslee,  W.  L.  Atlee,  and 
Lawson  Tait.  Dr.  Goodell  gives  a  fine  description  of  ovariotomy  in  his  Lessons 
in  Gynaecology,  p.  449,  1887. 


376 


TUMORS   OF   THE    OVARIES,   ETC. 


This. may  be  explained  by  the  theories  that  either  the 
cessation  of  ovulation  during  pregnancy  and  lactation 
acts  as  a  safeguard  against  the  growth  of  ovarian  cysts, 
or  that  the  sexual  relations  regulate  the  nervous  forces 
and  nutrition  of  the  ovary,  which  otherwise  might  be- 
come perverted  and  lead  to  the  growth  of  an  ovarian 
tumor.  While  these  tumors  are  most  common  between 
twenty  and  fifty  years  of  age,  i.e.,  during  the  greatest 
sexual  vigor,  they  may  occur  at  any  period  of  life,  in  new 
born  or  in  the  very  aged.  In  about  eight  per  cent  of  the 
cases  there  is  a  tumor  in  each  side  of  the  pelvis. 

Any  classification  of  these  tumors  must  be  necessarily 
faulty,  but  it  is  hoped  the  following  will  be  of  assistance 
to  the  reader  :  — 


f    Malignant  ^ 


Carcinoma 


[        Sarcoma 


I        Benign 


Hydatid  cysts 

Dropsy  of  "1 

the  Graafian  \ 

follicle  j 


f  Solid. 

\   Cystic,  most  common  form  of  can- 
[       cer. 

j  Combination  of  the  above,  and  sel- 
I       dom  seen. 
Very  rare. 


Fibroma 
Dermoid  cysts 


Ovarian   cysts 
proper 


Parovarian 

cysts. 


Common,  but  rarely  develops  to  any 
extent,  or  causes  any  symptoms. 

Very  rare,  and  hardly  ever  attains 

any  size. 
Not  common. 

C  Glandular,  from  proliferation  of 
epithelium,  and  the  constant  for- 
mation of  glandular  follicles. 

\  Papillary,  from  growth  of  connec- 
tive tissue,  and  the  formation  of 
vascular  papillae. 

-  Combination  of  these  forms. 


Malignant  Twnois.  —  It  may  be  laid  down  as  a  rule 
with  few  exceptions,  that  large  solid  tumors  of  the  ovary 

I  It  has  been  observed  that  malignant  disease  is  more  often  seen  in  countries  of 
an  older  settlement  rather  than  in  the  new,  as  in  the  United  States. 


CANCER   OF   THE   OVARY.  37/ 

are  malignant.  The  development  of  carcinoma  or  sar- 
coma may  be  primary  and  independent ;  but  either  not 
infrequently  complicates  cystic  degeneration,  particu- 
larly the  papillary  form,  though  the  latter  is  not  to  be 
considered  any  form  of  cancer.  Both  the  scirrhous  and 
medullary  varieties  are  found,  the  latter  being  the  more 
frequent. 

Cancer  may  develop  as  a  hard,  friable,  nodular  mass 
of  a  reddish  hue,  or  as  a  mass  of  globular,  cystic,  or  semi- 
solid cysts,  which  are  often  of  a  pale  straw  color  with 
very  friable  walls.  Adhesions  are  much  more  common 
than  with  benign  tumors ;  and  very  early  there  is  a 
tendency  to  invade  the  peritoneum,  in  the  shape  of 
nodules,  and  the  pelvic  cellular  tissue  through  the  pedi- 
cle of  the  tumor.  Both  ovaries  are  usually  affected. 
The  disease  develops  rapidly  with  symptoms  of  chronic 
peritonitis,  a  large  effusion  of  ascitic  fluid,  and  oedema 
of  the  feet  without  the  presence  of  cardiac,  hepatic,  or 
renal  disease  to  account  for  it.  The  well-known  cachexia, 
loss  of  strength,  local  pain,  and  sensitiveness  are  also 
marked  symptoms. 

The  researches  of  Drs.  Thornton  '  and  Foulis  ^  on  the 
microscopic  character  of  the  ascitic  fluid  are  of  great 
importance  in  the  diagnosis  of  malignant  disease.  With 
a  magnifying  power  of  three  hundred  and  fifty  diame- 
ters and  a  No.  3  ocular,  groups  or  masses  of  round  or 
oval  cells  with  large  nuclei  are  seen  ;  large  spaces  are 
present  in  the  centre  of  many  of  these  masses. ^  Sar- 
coma appears  not  unlike  a  fairly  symmetrical  hypertro- 
phy of  the  ovary,  similar  to  a  fibroid,  with  the  formation 
of  numerous  cysts,  giving  it  a  semi-solid  consistency. 
There  is  no  way  of  distinguishing  between  carcinoma 

I  British  Medical  Journal,  Sept.  7,  1878. 
^  Ibid.,  July  20  and  Nov.  2,  1S7S,  pp.  91  and  658. 

3  Some  fine  illustrations  of  these  are  in  Hart  and  Barbour's  Manual  of  Gynae- 
cology, 1886,  pp.  210,  217,  plates  ix.  and  x. 


378  TUMORS  OF   THE   OVARIES,   ETC. 

and  sarcoma  with  positive  certainty  while  both  are  in 
the  closed  abdominal  cavity.  The  absence  of  metasta- 
sis, and  greater  mobility  are  in  favor  of  sarcoma. 

Benign  Tnmors. — The  first  three  forms  of  benign 
tumors  may  be  passed  by,  as  they  are  either  pathological 
curiosities,  or  seldom  cause  any  disturbance.  Dermoid 
cysts  ■asQ,  comparatively  rare,  and  not  limited  to  any  age. 
They  seem  to  be  excited  to  activity,  and  peculiarly  prone 
to  suppuration,  after  the  traumatism  of  labor.'  They  are 
not  cured,  however,  by  the  discharge  of  pus  ;  this,  with 
the  escape  of  hair  and,  less  frequently,  teeth,  may  go 
on  for  an  indefinite  period.  These  cysts  are  believed 
to  originate  from  a  folding-in  and  enclosure  of  a  portion 
of  the  epiblast  during  foetal  life.  This  accounts  for  the 
true  skin  lining  the  cavity,  and  the  character  of  its  con- 
tents which  consist  principally  of  fat  (which  is  fluid  in 
the  body  but  which  rapidly  solidifies  at  a  lower  tempera- 
ture than  98°F.),  balls  of  hair,  teeth,  striped  muscle,  sar- 
comata,- and  pieces  of  bone.  Malignant  degeneration, ^ 
more  often  sarcomatous,  has  been  observed.  Dermoid 
cysts  vary  in  size,  grow  very  slowly,  or  may  remain 
dormant  for  years  without  giving  rise  to  any  symptoms 
so  long  as  they  do  not  degenerate. 

Ovarian  Cysts  are  more  often  of  the  glandular  variety, 
multilocular ;  and  the  larger  they  grow,  the  more  likely 
they  are  to  approach  the  unilocular  form  by  the  break- 
ing-down and  disappearance  of  septa,  leaving  one  cavity 
where  two  or  more  previously  existed.  The  contents 
of  the  cysts  are  of  a  complex  character  chemically,"*  and 

'  Barnes  :  Diseases  of  Women,  p.  337,  187S  ;  and  P.  Munde,  Arper.  Journal 
of  Obst,  p.  578,  vol.  xi. 

'^  Hart  and  Barbour's  Manual  of  Gynaecology,  p.  214,  1SS7. 

3  Centralblatt  fiir  Gynakologie,  No.  35,  p.  569,  18S6. 

*  For  a  description  of  thq  chemical  properties  of  ovarian  fluids,  see  a  paper 
by  Mr.  J.  Knowsley  Thornton,  Medical  Times  and  Gazette,  1876;  and  Eichwald, 
Coiloidentartung  d.  Eierstocke,  Wiirzb.  Med.,  Med.  Zeitschrift,  Bd.  v.  p.  270,  1864. 
Comp.  vol.  X.,  Ziemssen's  EncyclopEedia,  sub  Ovarian  Cysts. 


OVARIAN  AND   PAROVARIAN  CYSTS.  3/9 

vary  much  in  consistency  and  color  from  being  thin  and 
grumous  to  thick  and .  gelatinous.  The  corpuscular 
elements  of  the  fluid  are  numerous,  and  various  observ- 
ers differ  materially  in  their  descriptions.  Dr.  Drys- 
dale '  of  Philadelphia  has  described  a  corpuscle,  which 
bears  his  name,  and  the  presence  of  which  he  claims  is 
proof  that  the  fluid  containing  it  is  ovarian.  "  It  is 
generally  round,  delicate,  transparent,  and  contains  a 
nimiber  of  granules,  but  no  nucleus;"  acetic  acid  only 
makes  the  granules  more  evident.  His  experience, 
based  on  the  examination  of  many  hundred  specimens, 
is  worthy  of  careful  examination.  Dr.  Garrigues  ^  in- 
vestigated the  subject,  and  came  to  the  conclusion  that 
Drysdale's  corpuscles  are  merely  epithelial  cells  under- 
going fatty  degeneration,  and  not  diagnostic  of  ovarian 
fluid,  as  they  are  found  in  other  cysts  and  cavities.  He 
attaches  the  most  importance  "  to  the  presence  of  col- 
umnar epithelial  cells  seen  in  side  view."  The  question 
is  still  uncertain,  and  may  be  considered  sub  jiidice. 

The  papillary  form  of  ovarian  cystic  tumor  develops 
from  the  hilum  of  the  ovary.  Not  infrequently  the 
cyst-wall  ruptures,  retracts,  and  leaves  the  sprouting 
papillary  or  cauliflower-like  mass  projecting  into  the 
peritoneal  cavity,  causing  a  chronic  form  of  peritonitis. 
Dr.  Emraet^  and  Dr.  Foulis  hold  that  a  bloody  ascitic 
fluid  is  diagnostic  of  this  condition. 

Parovarian  Cysts  {cysts  of  tJie  broad  ligaments,  cili- 
ated epithelium  cysts)  are  not  so  rounded  as  those  of  the 
ovary  ;  are  covered  by  peritoneum  ;  contain  little  more 
than  salt  and  water;  and  are  distinctly  fluctuating.  As 
a  cyst  grows,  it  may  spread  between  the  folds  of  the 
broad    ligament,    and    consequently,    in    an    operation, 

'  Transac.  Amer.  Med.  Asso.,  1873  !  and  Transac.  Amer.  Gyn.  Soc,  18S2. 

2  American  Journ.  of  Obstetrics,  January,  April,  and  July,  18S2. 

3  Principles  and  Practice  of  Gynsecology,  pp.  683  and  684,  1S84. 


38o  TUMORS  OF   THE    OVARIES,   ETC. 

require  enucleation  on  account  of  the  absence  of  a 
pedicle,  which  in  ovarian  tumors  is  formed  by  the 
Fallopian  tube,  ovarian  and  broad  ligaments. 

The  Symptoms  of  benign  tumors  are  those  arising 
from  pressure,  and  anaemia  consequent  on  the  inability 
of  the  system  to  nourish  both  itself  and  the  growth. 
While  the  tumor  remains  small  in  the  pelvis,  no  symp- 
toms are  likely  to  arise.  The  abdomen  gradually  en- 
larges ;  there  is  a  feeling  of  weight  and  pressure,  with 
neuralgic  pains  in  the  pelvis ;  irritability  of  the  bladder, 
and  constipation  ;  later,  venous  distension  in  the  skin, 
hemorrhoids,  sometimes  diminution  of  urine;  ascites, 
dyspnoea,  and  cardiac  palpitation ;  gradual  failure  of 
health  ;  and  a  peculiar  anxious,  drawn  expression  of  the 
face.  Menstruation  is  seldom  interfered  with  until  the 
health  of  the  patient  has  very  much  deteriorated.  Not 
all  these  symptoms  are  likely  to  be  found  in  the  same 
case. 

The  physician  is  seldom  called  upon  to  diagnose  an 
extra-uterine  pelvic  tumor  till  it  has  risen  into  the 
abdominal  cavity. 

The  first  thing  to  decide  is,  whether  it  is  ovarian  ; 
the  second,  if  it  be  benign  or  malignant ;  and,  third, 
the  treatment  which  offers  the  best  chance  of  saving  or 
prolonging  the  patient's  life,  without  regard  to  swelling 
the  number  of  laparotomies  or  the  bank-account  of  the 
operator.  An  inexperienced  person  might  think  the 
diagnosis  easy  and  simple,  to  judge  by  the  elaborate 
descriptions  and  detailed  points  of  differential  diagno- 
sis as  given  in  various  treatises  on  the  subject  ;  but 
those  who  are  familiar  with  these  growths  in  their  varied 
conditions  know  too  well,  perhaps  more  here  than  in 
any  other  disease,  how  difficult  is  the  diagnosis  in  some 
cases,  and  simple  in  others.  It  cannot  always  be  deter- 
mined, even  by  an  exploratory  incision  ;  and  what  may 


EXAMINATION  AND   DIAGNOSIS.  381 

appear  to  be  the  simplest  case  before  commencing  an 
operation,  may  prove  exceedingly  difficult  to  complete. 

These  remarks  are  made  before  giving  the  points  of 
differential  diagnosis,  not  only  to  warn  the  examiner 
from  being  too  hasty  in  his  conclusions,  but  also  to 
offer  a  grain  of  comfort  if  he  has  made  a  mistake.  In 
very  doubtful  cases,  the  aspirator  may  be  used  to  obtain 
fiuid  for  chemical  and  microscopic  examination ;  but 
unless  there  are  urgent  reasons,  the  operator  had  better 
refrain,  as  it  is  apt  to  cause  a  localized  peritonitis  and 
adhesions,  while  the  results  obtained  are  not  likely  to 
be  of  much  practical  value,  except  the  examination  of 
the  ascitic  fluid  for  the  groups  of  cells  characteristic 
of  malignant  disease. 

The  Examination.  —  In  conducting  an  examination, 
the  patient  must  lie  on  her  back,  on  a  hard  table  or 
mattress,  with  the  knees  drawn  up,  the  abdomen  freely 
exposed,  with  all  constricting  clothing  removed.  She 
should  be  assured  that  she  will  not  be  hurt,  and  encour- 
aged to  relax  the  abdominal  muscles,  so  as  to  enable  the 
physician  to  thoroughly  examine  the  tumor.  The  pa- 
tient should  have  previously  free  evacuations  of  the 
bowels  by  enemata  or  mild  laxatives,  an  empty  bladder, 
and  in  all  doubtful  cases  anaesthesia  is  necessary. 
These  precautions  at  once  eliminate  fascal  impaction, 
distended  bladder,  and  phantom  tumor. 

On  inspection,  the  abdomen  is  seen  to  be  more  or  less 
distended,  sometimes  a  little  to  one  side  of  the  median 
line,  with  blue  veins  coursing  over  the  surface,  and,  not 
infrequently,  protrusion  of  the  navel  and  striae  on  the 
skin.  Fluctuation  in  fluid  cysts  is  often  readily  per- 
ceived. As  a  rule,  there  is  no  fluctuation  by  exter- 
nal palpation  in  small  tumors  which  do  not  extend  to 
the  umbilicus,  but  only  a  sense  of  elastic  resistance  to 
the  examining  fingers.       If  one    finger,    in    either   the 


382  TUMORS  OF  THE   OVARIES,   ETC. 

vagina  or  rectum,  can  be  placed  against  the  tumor,  fluc- 
tuation is  often  felt  with  the  aid  of  the  hand  outside. 
If  the  wave  is  extremely  distinct  and  superficial,  on 
external  palpation,  even  visible  to  the  eye,  and  produced 
by  the  slightest  tap  of  the  examining  finger,  the  cyst  is 
probably  unilocular  and  parovarian.  This  probability  is 
increased  if  the  tumor  is  flaccid,  of  slow  growth,  and 
produces  no  symptoms  causing  the  patient  to  complain. 

Multilocular  tumors  are  often  recognized  by  their 
nodular  shape,  irregular  resistance,  fluctuation  distinct 
in  one  place  and  indistinct  or  absent  in  another  place. 
Large  tumors  extending  above  the  umbilicus  without 
distinct  fluctuation  are  scarcely  ever  unilocular  cysts. 

The  reverse  of  these  conditions,  i.e.,  uniform  shape 
and  resistance,  and  distinct  fluctuation,  does  not  hold 
true  for  the  inference  of  a  simple  cyst.  The  main  cyst 
may  be  large,  and  present  all  these  features,  while  there 
may  be  many  smaller  ones  within  it,  or  deep  in  the 
abdominal  cavity,  which  give  the  tumor  all  the  charac- 
teristics of  a  proliferating  cystoma. 

The  tumor  lies  in  front  of  the  intestines,  so  that 
there  is  a  fixed  area  of  dulness  in  front  which  does  not 
change  with  the  position  of  the  patient,  showing  the 
tumor  cannot  be  free  fluid  in  the  peritoneal  cavity. 
There  is  evidently  an  abdominal  tumor  of  some  kind. 
If  of  pelvic  origin,  the  history  of  the  case  is  likely  to 
show  that  it  developed  from  below  upward.  If  the 
tumor  is  of  hepatic,  splenic,  or  renal  origin,  continuous 
dulness  on  percussion  from  above  downward,  with  the 
symptoms  of  disease  of  those  structures,  will  be  present. 

In  a  tumor  of  the  broad  ligament,  the  uterus  is  ele- 
vated in  proportion  to  the  size  of  the  tumor,  and  crowded 
toward  the  opposite  side  of  the  pelvis  ;  such  tumors 
also  extend  deep  into  the  pelvis,  are  immovable  when 
small,  and  admit  of  only  limited  motion  when  large.      If 


EXAMINATION  AND  DIAGNOSIS.  383 

there  be  a  tumor  in  each  broad  ligament,  the  uterus 
is  forced  up  between  them,  and  the  vagina  becomes 
cone-shaped,  at  the  apex  of  which  the  cervix  is  reached 
with  some  difficulty.  A  rectal  examination  is  very 
useful  to  confirm  the  diagnosis  of  a  cyst  of  the  broad 
ligament. 

The  diagnosis  of  a  sub-serous  tumor  in  other  situa- 
tions than  the  broad  ligament  is  often  difficult  or  impos- 
sible ;  but  the  deep  descent  of  the  tumor  into  the  true 
pelvis  behind  the  uterus,  the  immobility  of  the  pelvic 
portion,  the  rapid  growth,  ascites,  and  the  feeling  of 
papillary  excrescences,  indicate  a  sub  serous  tumor. 

The  length  of  the  pedicle  is  associated  to  a  certain 
extent  with  the  mobility  of  the  tumor.  The  size  and 
site  of  the  pedicle  can  be  often  ascertained  by  a  rectal 
examination  with  the  aid  of  ether  and  drawing  down 
the  uterus,  or  by  introducing  the  fore  and  middle  fingers 
into  the  rectum,  and  the  thumb  of  the  same  hand  up  the 
vagina  so  as  to  reach  the  cervix.  The  other  hand  on 
the  hypogastrium  depresses  the  uterus,  while  an  assist- 
ant draws  the  tumor  up  from  the  pelvic  brim  or  to  one 
side  of  it. 

The  use  of  the  sound  to  measure  the  cavity  of  the 
uterus,  and  to  ascertain  the  amount  of  motion  com- 
murticated  to  that  organ  by  moving  the  tumor,  while  the 
sound  is  in  the  cavity,  is  an  important  aid  in  determin- 
ing the  relation  between  them,  whether  connected  or 
independent  of  each  other. 

A  history  of  slow  development,  absence  of  inflamma- 
tion, and  presence  of  the  ordinary  menstrual  flow,  dis- 
tinguish an  ovarian  tumor  from  haematocele,  the  exu- 
dation of  cellulitis  or  peritonitis,  abscess,  fibroids  en- 
croaching on  the  uterine  cavity,  and  pregnancy. 

By  this  simple  process  of  elimination,  there  remain 
the  following  conditions  with  their  diagnostic  points  :  — 


;84 


TUMORS  OF   THE   OVARIES,  ETC. 


-  5- 


03 


'^■e. 
% 


3  -a 


6  S 


0' 

does 
till  a 

nnect 
rus. 

s 

3  J 

■"   0 

Often 

ange 
)or. 
Mo  CO 
th  ut< 

u      . 

5^ 

rt  .S 

3  -^ 

t5 

u  S.        ? 

s 

3 

§  i 


5"  -^  3  '^  ^ 

>—    c  3    J^ 

f=H  S  u    u    «J    n 

."2  -5  -S  .^  ^ 


15  S 


in  S 


^ 

0 

0 

> 

w 

rt  4J 

0  ~ 

0 

s 

*-" 

C 

u: 

>^ 

t 

<D 

■< 

c 

0 

c 

C 

" 

>. 

0 

u 

ate 
S  ■- 

a  2 
rt  f 

1-1 

rt 

tii 

1)     cj 

^ 

"«  b 


{-1     Sv 


•S  "ij  ^ 


0  g  .^  u  " 


E'o 


3 

c 

^ 

fe  s 

0 

d 

^ 

rt 

i-     V 

0  ■£ 

0 

0 

>. 

ni 

a 

C     3 

>  -0 

3 

J3 

3  -^ 
0       - 

<->    - 

3 

„- 

E  'S 

0  iS 

ta 

c 

<'S 

c    « 

*- 

?► 

5^      e  8:5 

-3  -S  ■£   E 
*j  _&  iS   o   "^ 

-  rt  Ts"  i  ■£ 


'  '5  "  jJ"  c   S   c 
i  ^  -  Ji  5  3   3 


rt         --=-    "^ 


M)-- 


S    -  •  -    3 


OJ 


1=  ^ 


e  d^ 


i< 


_  ^  2  3  " 
o   o   3  A  Q 


CC  J3  (-1 


—  !c        3  lit 

3    a!         CO' 


Pi    C 


-d 


•£        - 


fH  -a       f:5 


K^ 


6     O 


S-S 

O    o 


S  s 


^  '3.  iJ 


P.S 


E  &> 


■5^2 


U     3     3  "o 


CLINICAL    CASES. 


385 


Having  arrived  at  some  conclusion  as  to  the  kind  of 
tumor,  it  is  equally  important  to  ascertain  whether  it 
be  benign  or  malignant.  In  this,  the  symptoms  already 
given  will  be  a  guide,  as  well  as  the  following  table  :  — 


Benign  Tumors. 

No  history  of  heredity  ; 
health  not  affected  till  late  in 
the  disease  unless  there  is 
menorrhagia  ;  no  cachexia. 

Growth  slow,  especially  if 
fibro-cystic  ;  outline  fairly 
smooth  and  regular.  Large, 
solid,  benign  tumors  of  the 
ovary  are  scarcely  ever  seen. 
Not  much  pain  or  soreness  in 
the  abdomen  ;  ascites  rare  ; 
fluid  does  not  show  the  cell 
groups. 


Malign ani  Tumors. 

History  of  heredity  ;  health 
early  affected  ;  cancerous  ca- 
chexia. 

Growth  rapid  ;  outline  knob- 
by, irregular  ;  they  are  "Some- 
times large  and  comparatively 
hard.  A  large  amount  of  as- 
cites develops  early,  containing 
the  cell  groups  previously  men- 
tioned. Much  local  pain  and 
soreness  in  the  abdomen. 
Hardening  of  the  tissue,  and 
nodules,  are  felt  in  the  fornix 
of  the  vagina  and  broad  liga- 
ments when  the  disease  is  well 
established. 


The  diagnosis  of  adhesions  may  be  considered  im- 
practicable. The  history  of  peritonitic  pains,  fixation 
of  the  uterus  and  base  of  the  tumor,  with  a  varying 
amount  of  immobility  of  the  abdominal  wall,  which  will 
not  glide  over  the  surface  of  the  growth  during  respira- 
tion, would  lead  us  to  suspect  adhesions. 

The  Prognosis  of  ovarian  tumors,  when  allowed  to  run 
their  course,  is  decidedly  unfavorable.  Some  develop 
much  more  rapidly  than  others,  and  this  must  be  con- 
sidered in  expressing  an  opinion  as  to  their  duration. 
Ovarian  cystic  tumors  average  about  three  years  from 
their  beginning  to  the  death  of  the  patient.     She  is  not 


386  TUMORS   OF   THE   OVARIES,   ETC. 

likely  to  apply  for  relief  before  a  year  or  eighteen 
months  have  elapsed,  leaving  about  eighteen  months 
more  of  life  for  the  majority  of  cases.  A  few  instances 
have  been  reported  of  spontaneous  cure,  chiefly  by 
rupture.  The  strong  probability  is  that  these  were  par- 
ovarian cysts. 

The  Clinical  History  of  ovarian  tumors  as  they  pro- 
gress to  a  fatal  termination  cannot  now  be  studied,  but 
it  may  not  be  out  of  place  to  quote  the  eloquent  de- 
scription of  it  by  Dr.  West.  "  We  have  symptoms  of 
the  same  kind  as  we  see  towards  the  close  of  every  lin- 
gering disease,  betokening  the  failure,  first  of  one  power, 
then  of  another ;  the  flickering  of  the  taper,  which,  as 
all  can  see,  must  soon  go  out.  The  appetite  becomes 
more  and  more  capricious,  and  at  last  no  ingenuity  of 
culinary  skill  can  tempt  it ;  while  digestion  fails  even 
more  rapidly,  and  the  wasting  body  tells  but  too  plainly 
how  the  little  food  nourishes  still  less  and  less.  The 
pulse  grows  feebler,  and  the  strength  diminishes  every 
day,  and  one  by  one  each  customary  exertion  is  aban- 
doned. At  first  the  efforts  made  for  the  sake  of  the 
change  which  the  sick  so  crave  for  are  given  up  ;  then 
those  for  cleanliness  ;  and,  lastly,  those  for  comfort,  — 
till  at  length  one  position  is  maintained  all  day  long  in 
spite  of  the  cracking  of  the  tender  skin,  it  sufficing  for 
the  patient  that  respiration  can  go  on  quietly,  and  she 
can  suffer  undisturbed.  Weariness  drives  away  sleep, 
or  sleep  brings  no  refreshing.  The  mind  alone,  amid 
the  general  decay,  remains  undisturbed  ;  but  it  is  not 
cheered  by  those  illusory  hopes  which  gild,  though  with 
a  false  brightness,  the  decline  of  the  consumptive  ;  for 
step  by  step  death  is  felt  to  be  advancing;  the  patient 
watches  his  approach  as  keenly  as  we,  often  with  acuter 
perception  of  his  nearness.  We  come  to  the  sick- 
chamber  day  by  day  to  be  idle  spectators  of  a  sad  cere- 


CLTNTCAL    HISTORY  OF  OVARIAN   TUMORS.     387 

mony,  and  leave  it  humbled  by  the  consciousness  of 
the  narrow  limits  which  circumscribe  the  resources  of 
our  art." 

As  every  operation  has  its  indications,  it  also  has  its 
counter-indications.  In  case  of  advanced  kidney,  heart, 
or  malignant  disease,  and  the  presence  of  universal 
adhesions,  ovariotomy  should  not  be  performed.  The 
presence  of  such  adhesions  can  only  be  determined  by 
exploratory  incision,  which  is  always  advisable  in  doubt- 
ful cases.  In  exceptional  cases  of  malignant  tumors, 
at  a  very  early  stage  of  the  disease  before  it  has  spread 
from  the  pedicle  or  extended  to  other  organs,  ovariotomy 
may  be  performed,  but  even  here  the  rate  of  mortality 
is  very  high. 

It  is  a  matter  of  regret  that  so  many  embryo  surgeons 
with  the  ink  scarcely  dry  on  their  diplomas,  who  have 
not  seen  more  than  one  or  two  ovariotomies,  are  so 
ready  to  perform  this  operation.  While  it  is  true  that 
it  is  often  very  easy,  it  may  also  tax  the  skill  of  the 
most  experienced  operator ;  and  no  one  can  tell  which 
it  will  be  before  the  abdominal  cavity  is  opened.  The 
fact  that  Dr.  Keith  has  performed  seventy-six  consecu- 
tive ovariotomies  without  losing  a  patient,  or  that  the 
mortality  of  a  few  surgeons  is  less  than  three  per  cent, 
is  no  criterion  of  the  risk  to  the  patient  in  the  hands  of 
an  inexperienced  operator. 

Ovariotomy  is  described  in  so  many  text-books,  it 
will  not  be  given  here,  and  it  also  lies  outside  the  scope 
of  this  work,  as  it  is  an  operation  to  be  performed  only 
by  specialists.  Nevertheless,  the  author  desires  to  make 
a  few  important  suggestions  in  regard  to  it. 

I.  Cleanliness,  not  antiseptic  solutions,  and  the  most 
careful  attention  to  detail,  is  the  secret  of  success  in 
ovariotomy. 

II.  A  short  abdominal  incision  is  preferable  to  a  long 


388  TUMORS   OF   THE    OVARIES,   ETC. 

one.  A  very  large  cyst  can  be  removed  through  an 
opening  three  inches  long  by  turning  the  patient  on  her 
side,  puncturing  the  cyst,  and  drawing  the  cyst  out  as 
it  gradually  collapses,  tying  adhesions  as  they  come  in 
view.  It  is  better  to  divide  large  ones  with  the  thermo- 
cautery, and  to  sear  the  pedicle. 

III.  The  peritoneal  toilet  must  be  thorough,  and  not 
a  drop  of  blood  left  in  the  abdominal  cavity. 

IV.  Close  the  peritoneum  with  a  continuous  cat-gut 
suture  ;  '  then  insert  a  couple  of  silver  wires  through 
the  skin  and  muscles,  but  not  the  peritoneum.  Now 
bring  together  both  the  fascia  and  muscular  fibres  of  the 
recti  by  interrupted  cat-gut  '  sutures,  one-fourth  inch 
apart.  A  third  layer  of  cat-gut '  sutures  brings  together 
the  skin  and  adipose  tissue  ;  finally,  the  silver  wires  are 
twisted  together.  If  the  external  sutures  come  out  just 
at  the  edge  of  the  skin  and  sub-cutaneous  tissue,  and 
the  margins  of  the  wound  are  closely  brought  together 
by  strips  of  coarse  muslin  which  are  fastened  down  at 
either  end  with  collodion,  the  patient,  does  not  suffer 
nearly  so  much  pain  as  when  the  sutures  include  the 
skin  (I  believe  this  last  modification  originated  with 
Professor  Talbot). 

V.  Dress  with  iodoform  gauze  and  borated  cotton, 
and  if  there  are  no  marked  fluctuations  of  temperature 
do  not  disturb  it  for  ten  days.  The  highest  temperature 
is  more  often  seen  on  the  third  day,  and  in  the  most 
favorable  cases  varies  from  ioo°  to  102°  F.  The  cat- 
gut sutures  will  take  care  of  themselves.  The  silver 
wires  can  be  removed  in  twelve  or  fourteen  days. 

The  time  to  operate  is  whenever  the  tumor  is  found, 
no  matter  what  its  size  is,  if  the  patient  be  in  a  suitable 
condition.     Cool,  clear  weather,  with  a  westerly  wind, 

'  The  cAt-gut  must  have  been  prepared  in  juniper  nil,  and  not  a  drop  of  wnter 
allowed  to  touch  it. 


CLINICAL   CASES.  389 

is  the  most  favorable.  Tapping  the  cyst,  the  injection 
of  iodine,  and  electrolysis  are  not  only  attended  by 
danger,  but  are  far  less  efificacious  than  the  radical 
treatment  of  removal. 

It  is  a  matter  of  regret  that  medicine  cannot  cope 
with  surgery  in  the  treatment  of  ovarian  tumors.  Now 
and  then  patients  are  seen  who  positively  refuse  to  have 
an  operation  performed  without  trying  other  measures. 
In  view  of  this,  the  following  reports  of  cases  cured  by 
remedies  are  appended  without  comment,  leaving  the 
reader  to  form  his  own  opinion  :  — 

Apis.  —  Dr.  E.  M.  Hale  cured  an  ovarian  tumor  the 
size  of  a  child's  head  at  birth.  It  was  so  diagnosed  by 
Professor  Byford,  who  wished  to  remove  it,  and  a  time 
was  appointed  several  months  from  that  date.  Dr. 
Hale  was  applied  to,  and  prescribed  apis  in  a  peculiar 
manner.  Ten  or  twelve  living  bees  were  thrown  into  a 
teacup  of  hot  water.  Of  this  infusion  a  tablespoonful 
was  taken  every  four  hours.  In  a  week  a  perceptible 
decrease  was  observed  ;  and  before  the  time  for  the 
operation  had  come,  the  tumor  had  nearly  disappeared. 
—  Brit.  Jonr.  of  Horn.,  p.  428,  1871. 

Dr.  W.  S.  Craig  believes  that  apis  taken  internally 
after  tapping  an  ovarian  tumor  has  considerable  power 
in  checking  the  re-accumulation  of  the  fluid,  and  reports 
the  two  following  cases  :  — 

In  1856,  Miss ,  aet.  24,  observed  a  tumor  in  the 

abdomen  gradually  increasing  in  size  for  eighteen 
months.  It  was  a  firm  swelling,  lying  towards  the  left 
side  of  the  umbilicus.  Various  remedies  were  used 
unsuccessfully.  I  then  tapped,  and  withdrew  about 
eight  quarts  of  straw-colored  fluid  ;  the  abdomen  was 
carefully  bound,  and  apis  prescribed  to  be  taken  inter- 
nally three  times  a  day.     There  was  no  return  of  the 


390  TUMORSOF   THE    OVARIES,    ETC. 

swelling"  for  two  years,  when  I  again  tapped,  and  with- 
drew six  quarts  of  a  similar  fluid,  after  which  she  re- 
sumed the  apis.  After  some  years  she  married,  and 
though  she  has  had  no  children,  she  is  well,  and  free 
from  any  signs  of  the  disease. 

Miss ,  aet.  72,  had  an  ovarian  tumor  on  her  left 

side.  Medicines  had  failed  to  relieve,  and  her  physi- 
cian requested  me  to  tap.  About  five  quarts  of  fluid 
were  withdrawn,  and  the  abdomen  carefully  supported 
with  a  bandage.  Apis  was  given  for  a  length  of  time. 
She  died  six  years  afterward  of  bronchitis.  A  post- 
mortem was  permitted,  and  the  cyst  found  shrivelled 
to  the  size  of  a  walnut,  attached  by  a  pedicle  to  the 
ovary,  —  Brit.  Jour,  of  Ho7n.,  p.  309,  1874. 

Auric  Chloride.  —  Dr.  Tritschler  states  that  he  has 
cured  a  swelling  of  the  ovary  extending  to  the  umbili- 
cus, with  aurum  nat.  mur.  (chloride  of  gold),  and  has 
very  decidedly  improved  others  of  considerable  size. 
He  states  that  Martini  has  cured  five  extreme  cases  of 
ovarian  dropsy  with  the  same  remedy.  —  Horn.  Recorder^ 
p.  102,  May  15,  1887. 

Bovista.  — Girl,  ast.  13^.  Fluid  tumor  was  found  in 
the  lower  part  of  the  abdomen,  on  the  left  side.  It  did 
not  change  its  place  in  the  different  positions  of  the 
patient.  Bovista  6x.  was  given  for  four  weeks.  In 
three  weeks  the  patient  was  of  normal  size.  The  tumor 
was  supposed  to  be  a  parovarian  cyst,  but  its  character 
is  doubtful.  —  Dr.  E.  M.  Madden  :  Monthly  Horn.  Re- 
view, p.  471,  Aug.  I,  1 88 1. 

Dr.  Hawkes  reports  a  similar  case  cured  with  bovista, 
in  the  Organon  for  July,  1878. 

Bovista  seemed  to  have  a  beneficial  effect  in  a  case  of 
parovarian  cyst  reported  by  Dr.  S.  H.  Blake,  Monthly 
Horn.  Review,  Sept.  i,  1883. 


CLINICAL   CASES.  39' 

Bromide  of  Potash.  —  Mrs.  ,  ast.  48.     A  small 

tumor  was  felt  in  the  region  of  the  left  ovary,  which 
speedily  enlarged.  Iodide  of  potassium  was  thought 
to  have  a  good  effect  in  retarding  the  growth  of  the 
tumor.  Nevertheless,  it  grew  rapidly,  and  in  four 
months  extended  as  far  as  the  epigastrium  with  dis- 
tinct fluctuation.  Extreme  dyspnoea  was  relieved  by 
drawing  off  eight  ounces  of  a  dark-colored  fluid,  but 
very  severe  pain  in  the  region  of  the  tumor  followed 
the  operation.  Sir  James  Simpson  saw  the  case  in 
consultation,  and  recommended  bromide  of  potassium 
in  small  doses, — five  grains  three  times  a  day.  Hot 
poultices  sprinkled  with  turpentine  were  applied  to  the 
seat  of  pain.  The  latter  diminished,  but  the  tumor 
began  to  increase.  Two  weeks  later  Sir  James  Simp- 
son saw  the  case  again,  and  recommended  the  dose  to 
be  doubled.  The  tumor  began  to  diminish,  the  patient 
perspired  very  copiously,  and  passed  a  large  quantity  of 
dark-colored  urine. 

This  continued  for  two  months,  when  the  medicine  had 
to  be  omitted  on  account  of  an  attack  of  acute  gastritis. 
The  tumor,  which  had  been  very  much  reduced,  gradu- 
ally increased  so  that  in  two  months  more  it  was  nearly 
as  large  as  at  any  time.  Sir  James  Simpson  recom- 
mended the  bromide  of  potassium  in  fifteen-grain  doses 
three  times  a  day,  with  marked  benefit  and  none  of  the 
sickening  effects  she  had  experienced  with  the  smaller 
doses.  Under  the  continuous  use  of  bromide  of  potas- 
sium, the  tumor  gradually  diminished  in  size  ;  and,  wish- 
ing to  mark  the  amount  of  the  diminution,  the  patient 
was  desired  to  measure  the  width  of  the  abdomen  on  a 
level  with  the  umbilicus ;  within  three  weeks  the  de- 
crease was  from  forty-eight  to  thirty-three  inches.  In 
six  weeks  from  the  last  consultation  the  tumor  had 
disappeared,  and  the  patient  continued  to  enjoy  pretty 


392  TUMORS   OF   THE    OVARIES,   ETC. 

good  health.  —  Dr.  Miller  :  Edin.  Med.  Jourtial,  p. 
404,  November,  1868. 

Miss ,  aet.  32,  with  dark  hair  and  healthy  appear- 
ance. July  29,  1867,  she  complains  of  sharp  cutting- 
pains,  which  are  sometimes  most  agonizing,  felt  princi- 
pally in  hypogastrium  and  towards  right  iliac  region. 
The  pains  are  much  increased  by  walking ;  there  is 
slight  tenderness,  pressure  over  right  iliac  region,  and 
towards  the  groin.  The  abdomen  is  much  distended 
by  flatulence,  but  above  pubis  and  to  right  side  there  is 
a  suspicion  of  swelling,  as  if  bladder  were  over-distended. 
Bowels  costive,  urine  scanty  and  high-colored,  no  appe- 
tite, tongue  furred,  pulse  normal.  From  July  29  to 
Aug.  10  the  remedies  given  were  bry.,  bell.,  mere. 
Frequently  hot  sitz-baths  were  taken,  and  hot  poultices 
applied  to  the  abdomen.  The  pains  gradually  subsided, 
recurring,  however,  in  strong  paroxysm  from  time  to 
time  ;  the  flatulent  distension  disappeared,  and  then 
the  suspicions  of  tumor  were  fully  confirmed.  A  smooth 
tumor,  of  the  size  and  shape  of  a  cocoanut,  can  be  felt 
low  in  the  hypogastric  and  right  iliac  region.  The 
tumor  is  now  slightly  tender  when  pressed,  but  palpa- 
tion gives  no  evidence  of  liquid  contents. 

Aug.  T/f.  —  Pain  and  tenderness  have  now  disap- 
peared ;  the  tumor  is  evident  to  the  sight,  and  the 
patient  states  that  since  i^-pril,  1867,  she  has  noticed 
an  increased  size  of  her  bowels.  Graph.  3,  two  grains 
every  evening,  was  prescribed.  Atig.  ig. — The  attempt 
to  pack  a  trunk  has  caused  a  return  of  intense  pains  in 
the  right  iliac  region,  extending  through  the  bowels  and 
to  the  loins.  Bell,  i  was  first  given,  and  this  failing  to 
relieve,  conium  in  frequent  doses  was  prescribed  with 
good  results. 

Sept.  21.  — The  tumor  has  now  attained  a  large  size  ; 
it    feels    smooth    and    tense,    is    slightly    tender  when 


CLINICAL    CASES.  393 

pressed,  and  there  is  indistinct  fluctuation.  The  abdo- 
men, measured  round  in  a  line  with  iliac  crests,  is  thirty- 
six  inches.  The  urine  is  scanty,  and  there  arc  frequent 
painful  calls  to  pass  it.  Bromide  of  potassium,  gr.  xii.  ; 
aq.  dest.  §  vi  ;  a  dessert-spoonful  to  be  taken  three 
times  a  day  in  a  wine-glassful  of  water.  A  tepid  sitz- 
bath,  in  which  is  dissolved  a  teaspoonful  of  brom.  pot., 
is  to  be  used  every  forenoon,  and  during  the  day  an 
abdominal  compress  soaked  in  a  solution  is  to  be  worn. 

This  treatment  was  steadily  followed,  with  from  time  to 
time  a  few  days  interruption,  until  the  end  of  February, 
1868,  when  it  was  discontinued.  During  October  and 
November,  1867,  there  were  now  and  then  threatenings 
of  attacks  of  ovarian  pain,  which  were  speedily  relieved 
by  conium.  By  the  end  of  October  there  was  evident 
diminution  of  the  tumor;  this  diminution  steadily  con- 
tinued, so  that  by  the  end  of  February,  1868,  the  swell- 
ing was  scarcely  to  be  discovered  ;  and  by  April  it  had 
entirely  disappeared.  A  careful  examination  on  the 
30th  of  May  gave  the  same  results  ;  and  another  made 
in  August  afforded  no  trace  whatever  of  tumor,  the 
measurement  of  abdomen  taken  in  line  with  crests  of 
ilium  being  twenty-six  inches,  showing  a  diminution 
of  ten  inches. 

It  does  not  appear  necessary  to  discuss  the  nature  of 
this  case  ;  for  though  ovarian  tumors  do  sometimes  pre- 
sent great  difificulties  in  determining  their  seat  and 
character,  yet  in  this  instance  all  the  circumstances 
facilitated  the  diagnosis.  —  Ovarian  Cystic  Twnor,  by 
Francis  Black,  M.D.,  Brit.  y.  of  Horn.,  p.  54,  1869. 

Calc,  Carb.  —  Mrs.  K.,  aet.  40,  tall,  slender,  dark  hair 
and  eyes,  and  of  dark  complexion  ;  married,  but  had  no 
children.  Menses  regular,  but  rather  scanty  and  pain- 
ful. The  patient  had  been  suffering  for  two  years  or 
more  with  a  dull,  aching,  uneasy  sensation,  and  some 


394  TUMORS   OF   THE    OVARIES,   ETC. 

soreness  in  the  right  inguinal  region,  and  was  consider- 
ably emaciated.  On  examination  discovered  a  hard, 
smooth  tumor,  about  the  size  of  a  quart-bowl,  quite 
prominent  in  the  right  iliac  region,  which  I  decided  to 
be  an  ovarian  tumor.  As  there  seemed  to  be  an  acute 
inflammatory  action,  gave  lachesis  twice  a  week,  and 
continued  the  treatment  six  months.  I  examined  the 
tumor  again,  and  found  its  size  had  not  increased  since 
the  first  examination,  and  that  it  presented  about  the 
same  appearance  in  every  way  as  at  first.  The  patient 
then  went  back  to  allopathic  treatment,  and  I  lost  sight 
of  the  case  for  two  years,  when  to  my  surprise  I  was 
called  to  visit  her  again.  An  eminent  surgeon  had  been 
consulted,  and  pronounced  the  disease  ovarian  tumor, 
and  said  the  only  remedy  was  to  remove  it  by  a  surgi- 
cal operation.  I  now  examined  the  case  again,  it  being 
two  years  and  a  half  since  I  first  met  the  patient,  and 
found  the  tumor  to  be  about  three  times  as  large  as 
when  I  first  examined  it,  appearing  quite  firm  and  hard. 
I  expressed  a  desire  to  make  one  more  trial  with  medi- 
cine, to  which  she  readily  assented,  as  she  dreaded  an 
operation  with  the  knife.  The  remedy  selected  was 
calc.  carb.,  one  grain  every  evening,  which  was  con- 
tinued for  three  months.  The  tumor  now  appeared 
about  the  same  size,  but  softer  and  more  yielding. 
Calc.  carb.  was  continued  three  months  longer,  once  a 
week  at  night.  The  tumor  had  now  diminished  in 
size  ;  was  quite  soft  and  flabby.  This  gave  courage  to 
persevere,  and  the  same  remedy  was  continued  six 
months  longer,  once  a  week,  making  one  year  that  the 
patient  was  under  treatment.  There  was  now  no  hard- 
ness, and  very  little  fulness.  The  patient  seemed  to  be  so 
nearly  well  that  treatment  was  discontinued.  It  is  now 
a  year  and  a  half  since  the  last  medicine  was  given.  I 
saw  the  lady  a  few  days  ago  ;  remains  perfectly  well ; 


CLINICAL   CASES.  395 

menstruates  regularly,  and  is  now  forty-five  years  of 
age.  —  Charles  Sumner:  N.  V.  S.  Trans.,  1871,  p. 
312. 

Colocynth.  —  Mrs. ,  ?et.  38.    Trousseau,  and  later 

an  eminent  gynaecologist  in  New  York,  diagnosed  a 
small  ovarian  tumor  on  the  right  side.  She  had  not 
been  able  to  leave  her  room  for  a  year,  and  was  confined 
to  the  sofa,  A  firm  elastic  tumor  occupied  the  space 
between  the  uterus  and  vagina  anteriorly  and  the  rectum 
posteriorly,  completely  occluding  the  vagina,  and  ren- 
dering defecation  very  difficult.  It  seemed  not  to  be 
adherent  to  the  walls  of  either  passage.  Attempts  at 
walking  induced  paroxysms  of  acute  pain  across  the 
hypogastrium,  in  the  sacral  region,  and  around  the  hip- 
joint  ;  from  here  the  pains  extended  down  the  groin  and 
along  the  femoral  nerve.  The  pain  was  relieved  by 
flexing  the  thigh  upon  the  pelvis,  and  always  induced 
or  aggravated  by  extending  the  thigh.  Even  without 
the  provocation  of  motion,  there  were  frequent  and 
severe  paroxysms  of  pain  as  above  described.  The 
appetite  was  not  good,  and  digestion  feeble  ;  but  the 
general  condition  of  the  patient  was  good.  Nervous 
sensibility  was  very  great.  The  pains  had  been  ascribed 
to  the  pressure  of  the  tumor  upon  the  sacral  nerves. 

The  patient  had  a  dread  of  taking  opiates,  and  had 
used  them  sparingly.  I  was  requested  to  mitigate  the 
pains  if  possible,  no  hope  being  entertained  of  a  cure. 
With  no  definite  expectations  of  accomplishing  a  radical 
cure,  I  prescribed  colocynth  200,  a  few  pellets  to  be 
taken  whenever  a  paroxysm  of  pain  came  on,  and  to  be 
repeated  every  hour  during  the  paroxysm. 

Three  weeks  later  I  learned  that  the  paroxysms  had 
been  less  frequent,  much  shorter,  and  milder,  the  remedy 
appearing  to  control  them. 

Four  months  later  the  patient  walked  half  a  mile  to 


396  TUMORS   OF   THE   OVARIES,    ETC. 

my  office,  and  reported  that  she  had  had  no  pain  for 
a  month.  She  could  walk  half  a  mile  daily  without 
fatigue  or  pain,  and  had  resumed  the  charge  of  her 
household  after  an  interval  of  nine  years.  She  thought 
the  tumor  had  become  somewhat  smaller.  Being  about 
to  sail  for  Europe,  she  desired  some  more  colocynth, 
that  she  might  be  provided  in  case  the  pain  should 
return. 

After  four  years,  she  came  back  from  Europe.  I 
found  her  perfectly  well.  There  had  been  no  return  of 
pain.  Six  months  after  the  visit  made  just  before  her 
trip  to  Europe,  the  tumor  disappeared  from  its  position 
between  the  vagina  and  rectum,  and  was  plainly  percep- 
tible in  the  abdomen.  It  has  since  disappeared  entirely, 
and  nothing  Can  now  be  discovered.  —  C.  Dunham  : 
Hoinoeopathy  the  Science  of  Therapeutics,  p.  484. 

Miss ,  aet.   25,  suffered  for  five  years.     Extreme 

weakness  and  lassitude  ;  cannot  walk  much  on  account 
of  the  weakness  and  trembling  of  the  legs,  especially 
in  the  open  air,  —  when,  however,  the  other  symptoms 
are  better.  Worse  in  every  respect  from  heat  and 
warm  weather.  Walks  bent  over,  with  the  hand  applied 
to  the  right  side.  Sallow  complexion,  expression  of 
suffering  in  her  face.  Occasionally  has  a  sharp  pain 
like  a  stab  in  right  pelvic  region,  obliging  her  to  bend 
double  and  press  strongly  with  her  hand  on  the  part. 
Appetite  variable,  mostly  poor ;  sleeps  badly,  often 
wakes  tired ;  catamenia  too  soon  by  one  or  two  days, 
scanty,  dark-colored,  offensive,  accompanied  by  almost 
constant,  sharp,  cutting  pains,  obliging  her  to  bend 
double,  screaming  and  tossing  about  in  agony.  Diffi- 
culty of  breathing  during  menses.  During  the  interval, 
thick,  yellow,  offensive  leucorrhoea.  Bowels  constipated. 
A  well-defined  tumor  in  right  iliac  fossa,  about  the  size 
of  a  cocoanut,   feels   elastic  but   hard,   immovable,  and 


CLINICAL    CASES.  397 

the  seat  of  a  cutting  pain  at  intervals.  Much  bilious 
vomiting  during  the  attacks  of  colic.  Uterus  prolapsed, 
inclined  to  left  side,  and  immovable  owing  to  pressure 
of  the  tumor.  Under  previous  treatment,  the  tumor 
had  been  punctured  by  a  trocar,  once  or  twice  develop- 
ing fully  its  cystic  character. 

After  four  doses  of  colocynth  (one  a  week),  the  suf- 
fering at  the  menstrual  period  was  much  increased, 
though  there  was  no  flow.  Coloc.  im.,  single  dose, 
made  some  improvement.  A  month  after,  coloc.  loom., 
single  dose,  since  which  she  has  constantly  improved  in 
all  respects  ;  after  five  months  the  tumor  could  not  be 
detected,  and  she  feels  well. — Dr.  J.  G.  Gilchrist:' 
Med.  Investigator,  vol.  x.  p.  632,  1873. 

Graphites.  —  A  painful  swelling  of  the  breast  about 
the  size  of  a  walnut,  was  cured  in  a  fortnight  with  conium 
2x.  Subsequently  a  hard  round  tumor,  the  size  of  a 
large  orange,  was  discovered  in  the  right  iliac  fossa.  It 
reached  to  the  median  line  of  the  abdomen,  and  was 
nearly  joined  by  a  similar  hard  round  tumor  growing  up 
from  the  left  iliac  fossa. ^  These  tumors  were  hard, 
round,  and  slightly  movable  ;  hard  pressure  caused  a 
little  pain  ;  the  little  inconvenience  from  them  was  from 
their  weight,  which  seemed  out  of  all  proportion  to 
their  size.  The  patient  took  graphites  12  for  several 
months,  and  the  tumors  disappeared. 

Iodine  Water.  —  Dr.  Hirsch  of  Prague  reports  a 
case  of  ovarian  cyst  which  had  increased  so  much  as  to 
injure  the  health  of  the  patient.  He  at  first  gave  can. 
sat.  with  relief  to  the  dyspnoea,  cough,  and  scanty  urine, 
etc.,  but  no  marked  diminution  of  the  tumor  was  appar- 
ent.    He  then  prescribed  the  iodine  mineral  waters  of 

'  In  the  September  number  of  the  American  Observer  for  1877,  Dr.  Gilchrist 
has  collected  a  number  of  cases  of  tumors  cured  by  remedies.  Consult  also  an 
article  by  Dr.  Guernsey  in  the  Hahn.  Monthly,  p.  279,  1877. 


398  TUMORS   OF   THE    OVARIES,  ETC. 

Hall  in  doses  which  he  estimated  to  contain  the  forty- 
eighth  of  a  grain  of  iodine.  In  fourteen  days  the 
tumor  was  less,  and  in  four  weeks  it  had  entirely  dis- 
appeared. A  short  residence  in  the  country  completed 
the  cure,  and  four  years  had  elapsed  without  any  return 
of  the  tumor. — Brit.  J.  of  Horn.,  vol.  xx.,  1862;  ex- 
tracted from  Meyer  s  Allgenieine  Homdopathische  Zei- 
tujig,  May,  1862. 

Lycopodium. — Polycystic  ovarian  tumor  on  the  left 
side.  Diagnosis  was  made  both  by  careful  palpation, 
and  also  by  Simon's  method  of  exploration  per  rectum. 
Patient,  set.  47,  married,  sterile,  and  has  passed  the 
climacteric.  For  two  years  she  has  had  a  dull,  aching, 
uneasy  sensation  in  the  left  inguinal  region,  constantly 
growing  larger  on  that  side.  She  had  been  tapped,  but 
the  fluid  re-accumulated.  The  tumor  was  the  size  of  a 
child's  head.  Apis  was  tried  for  three  months  with  no 
effect.  Lycopodium  6x.  was  used  for  two  months,  and 
the  tumor  slowly  diminished;  then  lye.  I2x.  In  four 
months  the  tumor  was  one-half  its  former  size.  Lye. 
30  was  then  prescribed,  and  in  eighteen  months  there 
was  no  trace  of  a  tumor.  She  has  remained  well  for 
the  four  years  since  then.  —  Dr.  J.  R.  Kippax  :  Horn. 
Woidd,  Dec.  i,  p.  541,  1881. 

Thuja  and  Cantharis.  —  A  writer  in  the  Allgemeine 
Hom.  Zeit.,  vol.  xcv.  No.  20,  states  that  with  cantharis 
30  in  alternation  with  thuja,  he  has  completely  cured 
two  cases  of  ovarian  cysts  of  considerable  size.  —  Hom. 
Recorder,  p.  112,  May  15,  1877. 


LACERATION  OF   THE    CERVIX.  399 


ADDENDUM. 

LACERATION    OF    THE    CERVIX. 

Since  writing  the  chapter  on  this  subject,  and  de- 
scribing the  operation  for  this  lesion,  I  have  modified 
my  method  of  operating  on  some  cases  in  the  following 
manner.  The  position  of  the  patient,  assistants,  and 
instruments  are  the  same,  with  the  exception  of  Hage- 
dorn's  needle  forceps,  his  strong  cervix  needles,  and  the 
No.  3  catgut  hardened  by  chromic  acid  or  juniper  oil. 

The  cervix  is  freshened  in  the  usual  manner;  the 
raw  surfaces  carefully  cleansed  with  hot  water,  every 
particle  of  clot  being  sponged  away.  The  anterior  and 
posterior  lips  of  the  cervix  are  brought  in  contact  so 
that  the  freshened  surfaces  meet  each  other  accurately. 
Both  lips  are  then  seized  on  their  outer  surfaces,  near 
the  external  os,  between  the  short  sharp  points  of  a 
pair  of  gynaecological  bullet  forceps.  Beginning  at  the 
upper  angle  of  the  laceration,  the  Hagedorn  cervix 
needle  is  thrust  deeply  through  the  cervix,  which  is 
sewn  with  a  continuous  catgut  suture,  the  stitches  being 
taken  near  together  ;  when  one  side  is  sewn,  the  needle 
is  at  once  carried,  without  cutting  the  catgut,  to  the 
upper  angle  of  the  opposite  side  if  the  laceration  be 
bilateral,  which  is  sewn  up  in  the  same  way,  i.e.,  one 
continuous  piece  of  catgut  is  used  for  both  sides. 

The  bullet  forceps  are  then  removed,  and  an  ordinary 
silver  suture  inserted  at  the  same  place  so  as  to  hold 
the  lips   in    contact   should   the  catgut   loosen   prema- 


400  LACERATION  OF    THE   CERVIX. 

turely.  The  catgut  must  not  be  touched  with  water 
or  a  wet  sponge. 

After  the  sutures  are  all  in,  the  cervix  is  carefully 
dried,  and  powdered  with  a  little  iodoform.  A  strip  of 
iodoform  gauze  is  packed  loosely  in  the  vagina.  The 
patient  is  put  to  bed,  and  the  urine  is  drawn  with  a 
catheter  once  in  six  hours.  If  there  is  no  bad  odor  or 
discharge  from  the  vagina,  no  vaginal  douche  is  used, 
and  perfect  quiet  enjoined.  A  little  discharge  and 
some  odor  is  not  uncommon  about  the  fifth  or  sixth 
day  after  the  operation.  The  gauze  is  then  removed 
from  the  vagina,  and  a  small  carbolized  douche  with  a 
little  calendula  is  administered. 

The  use  of  douches  from  the  beginning  is  not  advisa- 
ble when  catgut  sutures  are  used,  as  the  water  softens 
the  suture  ;  nor  must  these  sutures  be  drawn  tight 
when  put  in,  but  only  just  snug  enough  to  hold  the 
parts  in  contact  with  as  little  traction  and  depression  of 
the  surface  as  possible. 

The  advantages  of  this  method  are  :  increased  rapidity 
of  operating  on  account  of  time  saved  in  not  twisting 
wires  or  tying  knots,  only  one  suture  to  be  removed, 
and  a  saving  of  pain  to  the  patient,  besides  equally  good 
results. 

The  author  does  not  claim  this  modification  of  this 
operation  as  his  own,  though  he  has  not  known  or  seen 
others  operating  in  this  way. 


IN  DEX. 


Abdominal  supporters 45 

how  to  make 46 

Abscess  of  ihe  labia 107 

of  the  labia,  therapeutics  of.     .     .  109 

of  the  pelvis 338 

Acute  metritis 271 

Adenoma  of  the  uterus 303 

Affections  of  the  climacteric  period      .  153 

Albuminuria  preceding  the  first  menses,  132 

Alexander's  operation 212 

Alum,  application  of      ......  27 

Amenorrhoea 157 

and  dysmenorrhcea 192 

case  cured  by  apis 165 

case  cured  by  arnica 165 

case  cured  by  cocculus     ....  165 

case  cured  by  euphrasia  ....  165 

case  cured  by  nux  moschata      .     .  i65 

digest  of  remedies  for 166 

general  treatment  of 159 

smartweed  for 166 

therapeutics  of 162 

Anomalies  of  the  climacteric  period     .  153 

Anteflexion  of  the  uterus 213 

Anteversion  of  the  uterus 213 

Aphthous  inflammation  of  the  vulva    .  77 

Application  of  liquids 25 

of  ointments  or  cerates     ....  26 
of    pencils  of   gelatine  or  cocoa- 
butter,  medicated 26 

of  powder 26 

Areolar  hyperplasia  of  the  uterus    .     .  273 

Ascarides,  treatment  of 79 

Atresia  of  the  genital  canal    ....  124 

Baycurn,  a  substitute  for  tannin      .     .  33 

Belladonna,  local  application  ....  28 

Bodily  posture,  influence  of    ...     .  3 

Boracic  acid,  local  application  of     .     .  28 

Bromide  of  potash,  local  application  of,  28 

Bromne,  application  of 33 


Calendula,  local  application  of    .     .     .       28 
Cancer  of  cervix,  Spiegelberg's  sponge 

tent  test  for 49 

of  the  ovary 37^ 

Cancer  of  the  uterus      .     .     .     .     .     .     3'° 

contra-indications  to  operating .     .     317 
diagnosis  at  an  early  period       .     .     314 
Cancer,     differential     diagnosis     from 

uterine  fibroids 294 

Cancer  of  the  external  genitals   .     .     .     315 

hysterectomy 3'^ 

palliative  treatment 320 

prognosis  of 3^9 

tifetment  of 3^6 

therapeutics  of 321 

Carbolic  acid,  local  application  of  .  .  29 
Castration  for  fibroid  tumors  ....     299 

Catalepsy 13^ 

Catgut,  preparation  of,  for  sutures  .     .       90 

Caustics 29-33 

Cellulitic  exudation,  diflferential  diag- 
nosis from  uterine  fibroids      .     . 
Cerates,  local  application  of    ...     . 
Cervical  canal,  how  to  cleanse  it  with 
dry  sponges,  peroxide  of  hydro- 
gen, syringe,  suction     .... 
Cervix,  dilatation,  indications  for     .     . 
dilatation  of,  with  tents    .... 
dilatation  of,  with  instruments  .     . 
elongation  of,  in  prolapsus    .     .     . 
diagnosis  of  laceration  of      .     .     . 
laceration  of,  indications  for  oper- 
ating   256 

sequelae  of  laceration  of  ...     .     255 

Cervix  uteri,  erosion  of 251 

laceration  of  .     , 251 

ulceration  of 251 

Change  of  life 131 

Chloral  hydrate,  application  of  .  .  .  29 
Chloride  of  zinc,  application  of  .  .  .  33 
Chlorosis 133 


293 
26 


5° 


55 
216 

25s 


402 


INDEX. 


Chorea  at  puberty  or  menstrual  periods, 

therapeutics  of 

Chronic  metritis 

Chronic  metritis,  case  cured  by  vera- 

trum  alb 

Cleansing  the  cervical  canal    . 

Climacteric,  ailments  of  the    . 

diet  and  hygiene  at  the     . 

period,  anomalies  of  the  . 

Clinical  cases.     Amenorrhoea  cured  by 

apis 

Amenorrhoea  cured  by  arnica  .  . 
Amenorrhcea  cured  by  cocculus  . 
Amenorrhoea  cured  by  euphrasia  . 
Amenorrhoea  cured    by   nux   mo- 

schata 

Chronic  metritis  cured  by  veratrum 

album 

Dysmenorrhcea  cured  by  aconite  . 
Dysmenorrhoea  cured  by  apis  .  . 
Dysmenorihoea,  four  cases  cured 

by  borax 

Dysmenorrhcea  cured  by  ignatia  . 
Dysmenorrhoea,  two  cases  cured  by 

nux  vomica 

Dysmenorrhoea  cured  by  sarsapa- 

rilla 

Dysmenorrhcea    cured    by    silico- 

fluoride  of  calcium 

Epilepsy  cured  by  bovista  .  .  . 
Epilepsy  cured  by  nitric  acid  .  . 
Epilepsy,    two    cases     cured    by 

cenanthe  croc 

Leucorrhoea  cured  by  ammonium 

carb 

Leucorrhcea  cured  by  bovista  .  . 
Leucorrhoea  cured  by  ceanothus  . 
Leucorrhoea  cured  by  secale  .  . 
Leucorrhcea,  two  cases  cured  by 

kreosote  

Membranous  dysmenorrhcea  cured 

by  borax 

Membranous  dysmenorrhcea  cured 

by  veratrum  vir 

Menorrhagia,  two  cases  cured  by 

bovista 

Menorrhagia  cured  by  cyclamen   . 
Menorrhagia  cured  by  nitric  acid  . 
Menorrhagia  cured  by  ustilago 
Metritis,  acute  form,  cured  by  nux 

vomica 

Metritis,  acute  form,  cured  by  rhus 

tox.    .     .     


PAGE 
142 

282 
22 
131 
131 
153 

165 
165 
165 
165 


PAGE 

Clinical  cases.    Metrorrhagia  cured  by 

cyclamen 181 

Metrorrhagia     cured    by    Faradic 

current 172 

Ovaritis  cured  by  ferrum  phos.  .  372 
Ovaritis  cured  by  graphites  .     .     .     372 

Ovaritis  cured  by  guiac 372 

Ovaritis    and    sterility    cured    by 

platina 371 

Ovaritis  cure  1  by  podophyllum     .     371 
Ovarian  neuralgia  cured  by  bella- 
donna       359 

Ovarian  neuralgia,  in  pregnancy, 

cured  by  ignatia 359 

Ovarian  neuralgia  cured  by  xan- 

thoxylon 360 

Ovarian  tumor,  four  cases  cured  by 

apis 389 

Ovarian  tumor,  one  case  cured  by 

auric  chloride 389 

Ovarian  tumor,  three  cases  cured 

by  bovista 389 

Ovarian  tumor,  two  cases  cured  by 

bromide  of  potash 391 

Ovarian  tumor,  one  case  cured  by 

calcarea  carb 393 

Ovarian  tumor,  two  cases  cured  by 

colocynth 395 

Ovarian  tumor,  one  case  cured  by 

graphites 397 

Ovarian  tumor,  one  case  cured  by 

iodine  water 397 

Ovarian  tumor,  one  case  cured  by 

lycopodium 398 

Ovarian  tumor,  one  case  cured  by 

thuja  and  cantharis 398 

Pelvic  cellulitis,  case  cured  by  ar- 

senicum 343 

Pelvic  peritonitis   cured  by  mere. 

sol 34S 

Procidentia     cured      by    arctium 

lappa 231 

Pruritus  vulvae,  two  cases  cured  by 

caladium  seg 80 

Pruritus  vulvse  cured  by  hydroco- 

tyle  asiat 82 

Pruritus    vulvse    cured    by    lapis 

albus 82 

Pruritus  vulvae  cured  by  mezereum  81 
Pruritus  vulvae  cured  by  rhus  tox.  81 
Pruritus  vulvae,   two  cases   cured 

by  sulphur 81 

Retroversion  cured  by  rhus  tox.    .     231 


INDEX. 


403 


PAGE 

Clinical  cases.     Retroversion  cured  by 

chloride  of  gold 231 

Sub-involution  cured  by  natr.  mur.  281 

Vaginismus  cured  by  cuprum   .     .  124 
Vicarious  menstruation   cured  by 

digitalis 185 

Vicarious   menstruation   cured  by 

lycopodium 185 

Vicarious  menstruation,  two  cases 

cured  by  Pulsatilla   .     .     .       183,  184 
Vicarious   menstruation   cured  by 

senecio 185 

Coil  suture 105 

Collection  of  faeces,  differential  diagno- 
sis from  uterine  fibroids     .     .     .  293 
College  graduates,  health  of  female      .  3-5 
Congestive  dysmenorrhosa      .    188,  190,  192 

Corroding  ulcer 311 

Crab-lice 78 

Curette,  the  use  of  the 57 

Cyanuret  of  zinc,  poisoning  by  .     .     .  200 

Cystitis 67 

Cystocele 205,  207 

Cysts  of  the  broad  ligament    ....  379 

Cysts  of  the  ovary 378 

Dermoid  cysts 377 

Differential  diagnosis,  benign  and  ma- 
lignant ovarian  tumors      .     .     .  384 
benign  and  malignant  sclerosis  of 

the  cervix 314 

cellulitis  from  fibroid  tumors     .     .  293 

fibroid  tumors  of  the  uterus  .     .     .  293 
fibroid  tumors,  sarcoma,  corroding 

ulcer,  cancer 315 

forms  of  dysmenorrr.cea  ....  190 
of  ovarian  tumors  from  many  other 

conditions 381-384 

pelvic  peritonitis,  pelvic  cellulitis, 
pelvic  abscess,  fibroid  or  ovarian 
tumors,  hsematocele      ....  336 
Dilatation  of  the  cervix  by  steel  dila- 
tors (Goodell's  method)     ...  55 

by  teals 48 

indications  for 50 

Digest  of  remedies  for  abscess  of  the 

lab  a no 

for  amenorrhoea 116 

for  dysmenorrhoea 202 

for  endomeritis 246 

for  leucorrhoea 246 

for  menorrhagia  and  metrorrhagia,  178 

for  ovaritis 373 


PAGE 

Digest  of  remedies  for  uterine  displace- 
ment    231 

Displacement  of  the  ovaries    ....  207 

Displacements  of  the  uterus   ....  205 

Drysdale's  corpuscles 378 

Dysmenorrhoea 186 

and  amenorrhoea 192 

and  steiility 191 

cured  by  apis 200 

cured  by  aconite 19s 

cured  by  ignalia 201 

cured  by  nux  vomica 201 

differential  diagnosis  of  its  forms  .  190 

forms  of 188 

membranous,  four  cases  cured  by 

borax 196 

membranous,   cured   by  veratrum 

vir 199 

therapeutics  of 195 

Eczema  of  the  vulva 77 

Education  and  uterine  disease     .     .     .3,4 

Electricity  for  adhesions 212 

for  amenorrhoea 160 

for  chronic  metritis 277 

for  dysmenorrhoea 192 

for  fibroid  tumors 296 

for  metrorrhagia 172 

for  pelvic  peritonitis,  cellulitis,  exu- 
dations of 342 

Emmet's  operation  for  laceration  of  the 

cervix 258 

new  operation  for  laceration  of  the 

perineum 104 

Endometritis 233 

accompanying  fibroid  tumors    .     .  284 

case  cured  by  ammonium  carb.      .  248 

case  cured  by  bovista 248 

case  cured  by  ceanothus  ....  248 

case  cured  by  secale 248 

complications  of 234 

digest  of  remedies  for 246 

fungosa 303 

therapeutics  of 241 

treatment  of 238 

Epilepsy 137 

case  cured  by  bovista 148 

case  cured  by  nitric  acid  ....  148 
two  cases  cured  by  csnanthe  cro- 

cata 146 

caused  by  picrotoxine,  active  prin- 
ciple of  cocculus  ind 146 

caused  by  cinchonidin      ....  148 


404 


INDEX. 


PAGE 

Epilepsy  caused  by  lead-poisoning  .     .  147 

therapeutics  of 142 

Epithelioma  of  the  cervix  uteri  .     .     .  312 

Erosions  of  the  cervix  uteri    ....  251 

Erotic  affections 149 

Etiology  of  uterine  diseases    ....  2-6 

Eucalyptus  globulus,  application  of      .  29 

Examination,  bi-manually 13 

details  of 9 

indications  for 11 

of  girls  and  unmarried  women  .     .  13 

Fallopian  tubes,  diseases  of  the  .     .     .  354 

Fi^ro-cystic  tumors 302 

Fibroid  tumors,  etiology  of      ....  284 

castration  for 299 

differential  diagnosis  from  cancer  .  294 
differential  diagnosis  from  cellulitic 

exudation 293 

differential  diagnosis  from   collec- 
tion of  faeces 293 

differential  diagnosis  from  haemato- 

cele 293 

differential   diagnosis    from    other 

conditions 293 

differential  diagnosis  from  ovarian 

tumors 294 

differential   diagnosis    from    preg- 
nancy        293 

diff-renlial  diagnosis  from  uterine 

flexions 294 

diflferential  diagnosis  of  the  varie- 
ties       292 

endometritis  accompanying  .     .     .  284 

ergot  for 298 

examination  for 287 

examination  for  extent  of  attach- 
ment    290 

examination  of  sub-mucous .     .     .  290 

hydrastis  canadensis  for  ...     .  298 

mineral  waters  for 296 

pathology  of 283 

prognosis  of 294 

relation  to  childbeanng     ....  285 

remedies  for 298,  307 

removal  by  laparatomy     ....  301 

soft 284 

treatment  by  electrolysis  ....  296 

treatment  of 295 

treatment  of  hemorrhage  from  .     .  296 

varieties  of 287 

Fissures  at  the  neck  of  the  bladder       .  62 

Fistute 126 


PAGE 

Flexion  of  the  uterus,  anteriorly      .     .  213 

laterally 215 

posteriorly 208 

Flushing  at  the  climacteric.   See  Thera- 
peutics of 154,  156 

Glycerine,  application  of 29 

Gonorrhoeal  vaginitis   and   endometri- 
tis              iiS,  241 

Goodell's  method  of  rapid  dilatation  of 

the  cervix  uteti 55 

Graafian  follicles 130 

Gymnastics  for  uterine  displacements  .  225 

Hsematocele 349 

differential  diagnosis  from  Uterine 

fibroids 293 

Headache  at  the  menstrual  peiiods  .     .  149 
Health  statistics  of  female  college  grad- 
uates    3-5 

Hemorrhage  from  the  uterus  ....  169 

therapeutics  of 173 

Hot-water  douche,  effects,  and  indica- 
tions for  it 34 

Hot-water  spinal  bag  for  uterine  hem- 
orrhage    170 

use  and  indications  for  it .     .     .     .  37 
Hydrastis  canadensi^,  local  application 

of 30 

Hygiene  for  girls 4-10 

Hypertrophy   of    the   uterus,   conges- 
tive      273 

Hysteria 137 

management  of 139 

therapeutics  of 142 

Hystero-trachelorrhaphia   .     .     .       258,  399 

Hysterrhaphia 218 

Ice-bag  for  dysmenorrho^a      ....  193 

use  and  indications  for  it .     .     .     .  36 

Introduction i 

Iodine,  local  application  of      ...     .  30 

Iodized  phenol,  local  application  of .     .  31 

Iodoform,  local  applic.ition  of      ...  31 

Inversion  of  the  uterus 218 

Iron,  local  applications  of 31 

Jequirity 31 

Labia,  abscess  of 107 

Laceration  of  the  cervix  uteri      .     .     .  251 
details  of  operation  (or      .     .       258,399 

effects  of 252 


INDEX. 


405 


Laceration  of  the  cervix  uteri,  indica- 
tions for  operating 256 

mortality   of  operation  f^r    .     .     .  257 
relation  of  operation  for  it  to  steril- 
ity        256 

sequelae- of 255 

Laceration  of  the  perineum     ....  85 

Emmet's  new  operation  for  .     .     .  104 

with  a  rectocele,  operation  for  .     .  gg 

without  a  rectocele,  operation  for  .  87 

I>ateral  flexion  of  the  uterus  .     .     .     .  215 

Leucorrhffia 235 

as  a  symptom  of  malignant  disease,  237 

case  cured  by  ammonium  carb.      .  248 

case  cured  by  bovisla 248 

case  cured  by  ceanothus  ....  248 

two  cases  cured  by  kreosote      .     .  243 

case  cured  by  secale 24g 

diet  for 237 

digest  of  remedies  for 246 

etiology  of 236 

forms  of 237 

from  specific  causes 237 

from  specific  causes,  treatment  of, 

118,  241 

local  treatment  for 238 

therapeutics  of 241 

Liquids,  local  application  of    ...     .  25 

Local  applications,  indications  for  alum  27 

for  belladonna 28 

for  boracic  acid 28 

for  bromide  of  potash 28 

for  calendula 28 

for  carbolic  acid 2g 

for  chloral  hydrate 29 

for  eucalyptus  globulus    ....  29 

for  glycerine 29 

for  hydrastis  canadensis   ....  30 

for  iodine  ....;....  30 

for  iodized  phenol 31 

for  iodoform 31 

for  iron 31 

forjequirity 31 

for  nitrate  of  silver 32 

for  opium 33 

for  pinus  canadensis 33 

for  tannin 33 

Local  treatment  for  cancer 320 

for  chronic  metritis 277 

for  cystitis 70 

for  eczema  of  the  vulva     ....  77 

for  endometritis 238 

for  fibroid  tumors  of  the  uterus     .  296 


Local  treatment   for  laceration  of  the 

cervix 257 

for  leucorrhoea 238 

for  leucorrhoea  from  specific  causes,  238 
for  menorrhagia  and  metrorrhagia,  170 
for  parasites  of  the  vulva      ...  78 
for  pelvic  cellulitis  and  pelvic  peri- 
tonitis      340 

for  prolapsus  uteri 217 

for  pruritus  vulvze 76 

for  prolapsus  vaginae 207 

for  retroversion 210 

for  uterine  displacements  with  ad- 
hesions      211 

for  urethritis 63 

for  vaginismus 121 

for  vaginitis 117 

for  vulvitis 113 

Malignant  diseases  of  the  sexual  organs,  310 

Marriage,  influence  of 4-7 

question  of,  in  uterine  diseases,  as 
amenorrhoea,  dysmenorrhoea,  fi- 
broid tumors,  and  hereditary  dis- 
eases,  as    cancer,    tuberculosis, 

insanity 7,  8 

Matico,  a  substitute  for  tannin     ...  33 

Membranous  dysmenorrhoea  .     .     .  i8g-i94 

four  cases  cured  by  borax      .     .     .  ig6 

cured  by  veratrum  vir igg 

Menorrhagia 169 

two  cases  cured  by  bovista    .     .     .  180 

case  cured  by  cyclamen    .     .     .     .  177 

case  cured  by  hydrastis    .     .     .     .  177 

case  cured  by  laurocerasus   .     .     .  177 

case  cured  by  nitric  acid  ....  175 

case  cured  by  ustilago      ....  181 

digest  of  remedies  for 178 

local  treatment  of 170 

therapeutics  of 173 

Menstrual  headaches 149 

toothache   . 153 

Menstruation,  painful 186 

physiology  of 130 

time  of  appearance 129 

time  of  cessation 131 

too  profuse 169 

vicarious 183 

Metritis,  acute 271 

cured  by  coflfea 272 

cured  by  rhus  tox 272 

Metritis,  chronic 273 

electricity  for 277 


4o6 


INDEX. 


PAGE 

Metritis,  local  treatment  of      ....  277 

therapeutics 278 

Metritis,  parenchymatous 273 

Metrorrhagia i6g 

case  cured  by  cyclamen    ....  181 

digest  of  remedies  for 178 

local  treatment  for 170 

therApeutics  of 173 

Minor  surgical  gynaecology    ....  9-58 

Myoma  of  the  uterus 283 

Myotomy     . .  301 

Neuralgic  dysmenorrhoea   .     .   188,  190,  191 

Nitric  acid,  application  of 33 

Nitrate  of  silver,  local  application  of   .  32 

Nymphomania 149 

Obstructive  dysmenorrbcea     .     .     .  189-193 

Ointment,  local  application  of     .     .     .  26 

Opium,  local  application  of     ...     .  33 

Outlining  the  uterus 13 

Ovarian  dysmenorrhoea      ....  188-192 

Ovarian  neuralgia 357 

Ovarian  tumors 375~378 

classification  of 376 

differential  diagnosis  from  uierme 

fibroids 294 

malignant 376 

four  cases  cured  by  apis  ....  389 
one  case  cured  by  auric  chloride   .  389 
three  cases  cured  by  bovista      .     .  389 
two  cases  cured  by  bromide  of  pot- 
ash       391 

one  case  cured  by  calcarea  carb.    .  393 

two  cases  cured  by  colocynth    .     .  395 

one  case  cured  by  graphites      .     .  397 

one  case  cured  by  iodine  water      .  397 

one  case  cured  by  lycopodium  .     ,  398 
one  case  cur  d  by  thuja  and  can- 

tharis 398 

differential  diagnosis    .     .     .     .381-384 

examination  of 381 

Ovaries,  displacement  of    .     .     .       207,  223 

diseases  of  the 362 

examination  of  the 362 

imperfect  development  of  the    .     .  363 

Ovariotomy 386 

Ovaritis 364 

and  sterility,  case  cured  by  platina,  371 

case  cured  by  ferrum  phos.  .     .     .  372 

case  cured  by  graphites    ....  372 

ca~e  cured  by  guiacum     ....  372 

case  cured  by  podophyllum  .     .     .  371 


PAGE 

Ovaritis,  digest  of  remedies  for   .     .     .  373 

local  treitment  of 367 

therapeutics  of    .     .    ' 368 

Ovary,  inflammation  of  the     ....  364 

Painful  menstruation 186 

therapeutics  of 195 

Papillary  ovarian  tumor 379 

Parametritis 324 

chronic  atrophic 324 

Parasites  of  the  vulva 78 

Parenchymatous  metritis 273 

Parovarian  cysts 379"38i 

Pelvic  abscess 343 

Pelvic  cellulitis 324 

clinical  history  of 326 

case  cured  by  arsenicum  ....  343 
diagnosis,  and  differential  diagnosis 

from  pelvic  peritonitis  ....  329 

local  treatment 340 

therapeutics 343 

Pelvic  haematocele 349 

clinical  history  of 351 

Pelvic  peritonitis 324 

case  cured  by  mere,  sol 345 

clinical  history  of 332 

diagnosis 334 

differential   diagnosis   from   pelvic 
cellulitis,  p.-lvic  abscess,  fibroid 

or  ovarian  tumor,  haematocele    .  336 

etiology  of 330 

local  treatment 340 

prognosis 337 

therapeutics 343 

Pencils,  gelatine  or  cocoa-butter,  medi- 
cated    26 

Perimetritis 324 

Perineal  fascia,  injuries  to,  and   their 

effect 84 

Perineal  laceration,  forms  of  ....  85 

Perineorrhaphy  with  a  r.  ctocele       .     .  98 

without  a  rectocele 87 

Perineum,  when  to  operate  on  a  lacera- 
tion of  the 85 

Pernitrate  of  mercury, application  of  the,  33 

Pessaries,  anteversion 42 

introduction  of 40 

moulding  and  fitting  of    .     .     .      39-41 

retroversion 39 

rules  for 41,  47,  48 

soft  rubber,  removal  of  odor  from,  42 

stem 52 

varieties  of 38,  43,  44 


INDEX. 


407 


PAGE 

Pinus  canadensis,  local  application  of   .  33 

Pin-worms,  treatment  of     ....     .  79 

Pollutions  in  females 149 

Polypi  of  ihe  uterus 303 

Powder,  local  application  of    ...     .  26 
Pregnancy,  differemial  diagnosis  from 

uterine  fibroids 293 

Probe,  how  and  when  to  use  the  uterine,  i5 

Procidentia  uteri 216 

Procidentia  uteri,  case  cured  by  arctium 

lappa 231 

Prognosis  for  uterine  displacements      .  226 

for  uterine  polypi 304 

Prolapse  of  the  mucous  membrane   of 

the  urethra 61 

Prolapsus  uteri 215 

vaginse 207 

Pruritus  vulvae 75 

caused  by  drinking  coffee      ...  82 

caused  by  lapis  albus  .....  82 

diet  for 76 

etiology  of 75 

local  treatment  of 76 

therapeutics  of 79 

Puberty 129 

albuminuria  just  before    ....  132 

Puerperal  state,  care  in  the     ....  275 

Rapid  dilatation  of  the  cervix      ...  53 

Rectocele 205 

Retroflexion  of  the  uterus 208 

treatment  of 209 

with  fixation,  treatment  of    .     .     .  211 

Retroversion  of  the  uterus      ....  208 

cases  cured  by  chloride  of  gold      .  231 

cured  by  rhus  tox 231 

treatment  of 209 

Rules  for  the  use  of  stem  pessaries       .  53 

for  the  use  of  tents 53 

Salpingitis 354 

Sarcoma  of  the  ovary 377 

Sarcoma  uteri 311 

Sexual  fraud,  effect  of 5 

Silk,  how  to  coat  it  with  carbolized  wax,  90 

Sims'  position  . 22 

Sound,  indications  for  using  the  ...  16 

how  to  replace  the  uterus  with  the,  18 

Speculum,  introduction  of  the  bivalve,  21 

of  the  Ferguson  or  cylindrical  .     .  20 

of  the  Sims' 22 

Sponge  tent,  test  for  cancer  of  cervix 

(Spiegeiberg) 49 


PAGE 

Stem  pessaries 52 

rules  for  use  of S3 

Sterility  and  dysmenorrho:a    ....  191 
relation  of,  to  operation  on  lacer- 
ated cervix 256 

Sub-involution 273 

case  cured  by  natr.  mur.       .     .     .  281 

Super-involution 273 

Tampons  of  absorbent  cotton,  cotton, 

tow,  wool 24 

how  to  make 25 

medication  of 25 

Tannin,  local  application  of    ...     .  33 

Tents,  how  to  use  them 48 

of  corn-stalk,  laminaria,  sponge, 

tupello 49 

rules  for  use  of 53 

Therapeutics  of  albuminuria  preceding 

puberty 132 

of  abscess  of  the  labia     ....  109 

of  amenorrhoea 162 

of  chlorosis 134 

of  chorea 142 

of  climacteric  period 154 

of  cystitis,  acute  and  chronic    .     .  71 

of  dysmenorrhoea 195 

of  endometritis 241 

of  epilepsy 142 

of  fibroid  tumors  of  the  uterus      .  307 
of  hemorrhage  from  the  uterus,  173,  307 

of  hysteria 142 

of  leucorrhoea 241 

of  menorrhagia  and  metrorrhagia,  173 

of  menstrual  headache      ....  151 

of  menstrual  toothache     ....  153 

of  menstruation,  painful  ....  195 

of  menstruation,  vicarious   .     .     .  184 

of  metritis,  chronic  and  acute  .     .  278 

of  ovarian  neuralgia 359 

of  ovaritis 368 

of  polypi  of  the  uterus      ....  308 

of  urethral  diseases 63 

of  uterine  displacements  ....  227 

of  vaginismus 123 

of  vaginitis 118 

of  vicarious  menstruation      .     .     .  184 

of  vulvitis 118 

Toothache  at  menstrual  periods .     .     .  153 

Trachelorihaphy 258 

Trance 138 

Trichiasis 76 


4o8 


INDEX. 


PAGE 

Ulceration  of  the  cervix  uteri     ...  251 

Urethra,  diseases  of  the 59 

Urethritis 62 

Uterine  displacements 205 

digest  of  remedies  for .     ....  231 

effect  of  pregnancy  on     ....  212 

fixed  by  adhesions,  treatment  of    .  211 

gymnastics  for 225 

prognosis  for 226 

Uterine  displacements,  shortening  the 

round  ligaments  for 212 

therapeutics  of 227 

Uterine  fibroids 283 

medical  treatment  of 306 

Uterine  flexions,  differential  diagnosis 

from  uterine  fibroids     ....  294 

Uterine  hemorrhage 169 

Uterine  polypi 3°3 

medical  treatment  of 306 

prognosis  of 303 

Uterus,  anteflexion  of 213 

anteversion  of 213 

congestive  hypertrophy  of    .     .     .  273 

curetting  the 57 

displacement  with  fixation,  treat- 
ment of 211 

hemorrhage  from,  treatment  of      .  173 

inversion  of 218 

inversion  of,  diagnosis      ....  219 
inversion  of,  prognosis      .     .     .     .  219 
inversion  of,  treatment  by  amputa- 
tion       223 

inversion   of,  treatment  by  elastic 

pressure 221 


PAGE 

Uterus,  inversion  of,  treatment  by  im- 
mediate reposition 220 

outlining  the 13 

retroflexion  of  the 208 

retroversion  of  the 208 

Vagina,  prolapse  of  the 207 

Vaginitis m 

local  treatment  of 117 

therapeutics  of 118 

Vaginismus 121 

case  cured  by  cuprum      ....  124 

operation  for 122 

therapeutics  of 123 

Vascular  growths  of  the  urethra      .     .  59 

Vicarious  menstruation 183 

case  cured  by  digitalis      ....  185 

case  cured  by  lycopodium     .     .     .  185 

two  cases  cured  by  Pulsatilla     .     .  185 

case  cured  by  senecio 185 

therapeutics  of 184 

Vulva,  abscess  of 107 

aphthae  of 77 

eczema  of 77 

itching  of  the 75 

itching  of  the,  therapeutics  of  .     .  79 

parasites  of  the 78 

trichiasis  of  the 76 

Vulvitis,  local  treatment  of     ...     .  113 

theiapeutics  of 118 

Zinc,  poisoning  by  the  cyanuret  of  .     .  200 


MEMORANDA. 


These  pages  are  designed  for  the  recording  of  cases,  verified 
symptoms  of  remedies,  or  other  information  which  the  reader  may 
wish  to  preserve.  The  author  earnestly  recommends  such  records, 
and  hopes  the  reader  will  kindly  send  him  a  copy  of  all  such,  or 
else  publish  the  same.  It  is  only  by  accurately  and  repeatedly 
recording  cases  cured,  and  verified  symptoms,  that  the  art  of 
prescribing  remedies  can  be  perfected. 


PAGE   OF 
BOOK. 


MEMORANDA. 


A.  — B. 


409 


PAGE  OF 
BOOK. 


MEMORANDA. 


c. 


410 


■AGE   OF 
BOOK. 


MEMORANDA. 


D. 


4(( 


PAGE   OF 
BOOK. 


MEMORANDA. 


E. 


412 


PAGE   OF 
BOOK. 


MEMORANDA. 


F.  — G. 


413 


PAGE   OF 
BOOK. 


MEMORANDA. 


H.-I.-J. 


414 


PAGE   OF 
BOOK. 


MEMORANDA. 


K.  — L. 


4f5 


"1^^°"  .  "  MEMORANDA.  M. 


416 


PAGE  OJ 
BOOK. 


MEMORANDA. 


M.  — N. 


417 


PAGE  OF 
BOOK. 


MEMORANDA. 


o. 


4f.S 


PAGE   OF 
BOOK. 


MEMORANDA. 


4C9 


•"^^ook"!'  memoranda.  0.  —  R. 


420 


PAGE   OF 
BOOK. 


MEMORANDA. 


421 


PAGE   OF 
BOOK. 


MEMORANDA. 


T.  — U. 


422 


PAGE   OF 
BOOK. 


MEMORANDA. 


v.  — w. 


433 


PAGE   OF 
BOOK. 


MEMORANDA. 


X.  — Y. 


424 


DATE  DUE 

— " 

-m^ 

)i2m- 

.,nfn9  i 

?  7n?M 

i-tUm 

. 

DEMCO  38-296 

COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

RG  95  .S68  1888  C.1 

A  practical  manual  of  gynaecology  / 


2002254808 


